Chapters Transcript What Spine Surgery can (and Can't Do - An Honest Appraisal Kumar Vasudevan, MD, discusses spinal anatomy, surgical vs nonsurgical causes of pain. Thanks very much for inviting me. Um I wanted uh I've been been with you all before to uh discuss uh brain tumors and wanted to take the chance to talk to you about another part of my practice, which is spine surgery. And um I think, you know, one of my goals uh for today is to hopefully open the door a little bit. Uh and uh clear up the, the black box that can sometimes happen when folks get sent uh to a neurosurgeon or to a spine surgeon uh and try to help uh give give everyone an honest understanding of what we can and cannot do. Uh because inevitably anybody involved uh in the care of patients in the modern age is going to see folks who uh are considering or have had uh spine surgery uh and uh know how to address those issues. Uh So, first of all, I have no uh disclosures and some of the goals for today are to just kind of review uh some basic spinal anatomy, some surgical and nonsurgical causes of, of pain. And then to really uh from the standpoint of uh non uh spine surgeon to help to understand what happens to patients who are going spine surgery, what we can do and can't do and, uh, really what, what, how you all can help us in terms of max, the, the, the chance of success with a spine surgery patient. Um, this is not a talk about back pain. Um, those, uh, you know, it's a very worthy topic to discuss about, uh, the things that go along with that I'll try to touch on some of those issues but really want to try to keep this, uh as, as uh focused on the surgical aspect of things as, as possible. Uh Just a reminder, uh, as Nikki said, I'm, I'm uh here uh primarily based at Christian Hospital. Uh And uh, we're, we're grown to provide full service, uh neurosurgical care for both brain and spine, uh integrated with the local providers here and uh with was U as well. And, um, uh we're very, very, uh excited about what we're building here. Um And, uh, say that as a preface to all of us. So, um I always like to start with a few kind of take points if you remember nothing else. So hopefully these points will stick with you. Uh The first is that uh the majority of back pain is not surgical. Um This is something that uh is, is a frustrating reality, I think for a lot of, uh folks, especially on the non surgical side and we'll talk about why that is, um, and we'll also talk about why, you know, some of these patients end up getting surgery anyway. Uh, even if their back pain is not, is not surgical. Another point is that, uh, you know, we don't have, uh, a huge amount of randomized evidence at this point to support spine surgery and especially spine fusion surgery. But, uh, for reasons, I'll show you a lot of experience that we have tells us that it does work and we're learning to uh study that better and refine our indications better. Based on that. A third point is that non surgeon providers can oftentimes provide just as essential of a service as we surgeons are, um, in trying to identify patients who might, might benefit the most from uh from surgery. And I'll, I'll let you know how you can help us with that as well. And finally, the risks of spine surgery while they're rare, they can be very serious. And an important part of the decision making, uh for any patient undergo these operations, no matter how much pain they may be in, is to consider those risks and whether they outweigh the benefits, uh or whether they uh the benefits outweigh the risks of, of surgery like that. So really the, the, the kind of patient that I'm hoping to address most with, with uh this talk is what you see here. And this is a common scenario and anybody who sees undifferentiated uh patients uh either on the primary care side or elsewhere, uh which is you have these two patients and, and the patient on the left is a, you know, youngish to middle aged male, um who has severe back pain, unable to work the back pain. Um And what I'm showing you there is essentially a normal MRI. There's no stenosis, there's no disc degeneration, there's no misalignment of the bones. This is a patient that uh is, is really in severe pain and quite miserable despite having a normal MRI. And then on the flip side, you have the patient on the right. This is a, you know, elderly female, um who maybe had a possible fracture on x-rays. This was followed with an MRI and without even being able to look at the specifics of that MRI, you can see that there's multilevel degeneration and all the, the discs here between the different bones, um and the compression of the neural elements in, in many places, but this patient has no pain. And so what do we do with that information? And, and uh you know, what, how does that inform our decision making? And uh as a spine surgeon, you know, these two patients walk into our office every single day, um and uh trying to figure out how to deal with them as part of the art uh of the, of the field and really, you know, spine surgery, I think, uh in, in years past has generated somewhat of a middling reputation. Um, and I think it's because for a time and hopefully decreasing as we go on now, uh, we were overtreating these patients. I think patients were getting a lot of spine surgery for a number of different reasons. First of all that, it is financial, financially lucrative for all the parties involved. Uh, that of course, is an incentive to do more procedures. Uh, it is difficult to study rigorously. It's tough to randomize patients uh to receive specific kind of interventions, given the heterogeneity and the symptoms that they may have, uh the different urgencies and symptoms that they may have. And of course, the uh the comorbidities that may have as well. And then I think most importantly, these are chronically debilitating symptoms. So you have patients that are unable to work or unable to do the things they like to do because of this pain, uh complain a lot of how much they're affecting their life and it drives well, meaning folks to want to do something for them. And so I think all those things make it again a recipe for, for overtreatment and, and that also makes it right, you know, right for something like this, which is kind of non physician providers to enter the, the, the space and say, look, you know, I have the answer. Somebody told me that these, these crazy doctors told me I had a herniated disc and I had so much pain, but I ate this or I did this specific exercise or I went to this person and I'm all better. And obviously these are not rigorously studied. Uh, this is all anecdotal but, you know, our patients see this and, and, um, our patients, uh, are, are looking for ways to feel better and it's on us to try to combat some of this with good evidence based care. This is another uh finding I found online of, you know, somebody who had, uh what in our fields is relatively straightforward small surgery, uh of uh removing a little bit of bone. Uh And by all accounts, looks like a successful surgery here, but they came to the conclusion of never a spine surgeon cut a hole in your back because of whatever outcome they've been they've been experiencing. So again, it's on us. Uh, you know, this information is out there and unfortunately, you know, it's not an uncommon thing for patients to experience. And so I wanna try to shed some light on that. It's unsurprising that if you look at the trend of, of surgeries being done, uh both in terms of the absolute number of surgeries and then the per capita rate of surgeries, it's steadily marching up over time with the expected dip, uh, you know, due to the due to the pandemic. But uh if you were to extend this line, no doubt that it's going up and up and up and you know, this, of course, is somewhat related to the generalized aging of the population. But no doubt that this is becoming more prevalent in the patients that we serve. So let's go through this point by point, I want to start off with the idea that the majority of back pain is not s and, and uh, you know, I think anybody again who works, especially in the primary care space knows this intuitively, but I want to delve into it a little bit more. And so the first is if we look at the spine, now, what, what exactly in the spine can hurt on the right side of the screen. Here, we have basically a a several vertebrae and some of the surrounding structures around them. What you see here is sort of the pink uh areas between the bones. These are of course, the intervertebral discs, the shock absorbers, as I like to say, between the bones and the spine. And then in the back part of the spine here, you have joints which connect the spine together give the spine mobility. These are the facet joints. Um And then these red structures in between emanating out from the spinal cord are the nerve roots which run into the arms into the legs and carry sensory and motor signals there. Now, any of these uh these structures can generate pain, of course, different, different kinds of pain, uh including the muscles and ligaments which attach the spine, which you're not seeing here. That's, that's the majority of acute spinal pain that you all are going to see. Uh and that's, you know, garden variety sprain strain, that sort of thing, which is exceedingly painful, but does not have a cause. We can necessarily point to on an MRI scan, that is the problem. But then other things such as the facet joints, the disc, the nerve roots and, and the bones, we can see those very well on imaging. And some of them do show signs from time to time of the generation or changes on imaging. And it's us, it's up to us to try to figure out whether what we're seeing is related to what the patient is feeling. So basically anything and everything you can think of if you point at the back can be a potential generator of pain. This is the idea of the functional spinal unit or the FSU basically looking at a, a schema of two different uh uh bones, two different vertebrae. These are uh likely thoracic vertebrae with the disc in between them. And all of these different things that you see here, the facet joint in the back, the intervertebral disc, the bones of course, on either side are interacting with each other to give the right balance of mobility to the spine as well as stiffness that is needed to support the spine. And when we're young, that balance is in is in good check, we're able to maintain the stability of the spine while being very flexible. Um And all of these mechanisms that you see here uh with the generation over time, uh can start to become less effective and can lead to particular kinds of symptoms. And this is, if you've been through any back pain lecture, you've seen something like this before, which is, you know, back pain is back pain. But then when it's accompanied by some of these red flag symptoms such as numbness, tingling, weakness, sudden changes in walking or balance, urinary or bowel symptoms. These are things that say that, ok, there's something more than garden variety back pain going on here and something that requires more attention and on the right side, you kind of notice, you know, some of the aspects of history uh that a patient might have, for instance, any patient with a history of cancer, any patient with a recent trauma, especially uh as they get older, even minor traumas can do this unexplained weight loss. Again, the things that we all would expect when you see a concerning symptom, uh uh along with something like that, it should draw attention. And then some folks talk about worsening pain greater than six weeks. In spite of therapy and exercise. It's kind of the distinction between acute and sub acute back pain in that most acute back pain is going to get better without us really doing anything. Once you get past six weeks, we get into the realm of needing to try something to try to understand a little bit more about what's going on. So this is there's many, many different ways, umpteen ways to kind of sub divide chronic spinal pain. And I wanna do it in a, in a way for you that my simple surgeon brain can understand. And, and so here's the way I sort of think about it. Uh There's the idea of specific back pain, which is basically saying we have something on an image or we have some sort of clinical syndrome that we can point to and say there is a very reasonable an atomic explanation for the pain that you're having. And, and these tend to be for the most part things that are quite, quite obvious, they're either causing neurological problems such as myelopathy with core compression, radiculopathy from, from compression of the nerve roots, neurogenic claudication, compression of the multiple nerve roots in the spine, a disc herniation or extrusion. These things you can point to on an MRI scan or AC T scan and say, look, I think, you know, as long as your, your history correlates with these, we have an excellent uh an excellent explanation for your pain if patients do have red flags, uh such as the ones we talked about. Again, those are things we can often times point to on an MRI scan and those are the ones that you wanna send immediately, you know, to a surgeon uh to evaluate and these are the things such as fractures, tumors, infections, inflammation, or the Ko QA syndrome, which we'll discuss a little bit further on in the lecture today. And then that's, that's sort of the, the easier side if you would say to deal with. And the more difficult side is what do we do about this non-specific pain, which really is quite, I think more common and the undifferentiated patient and something that you cannot point to anything on an imaging no matter how much pain patients are in and say this is the cause of your pain. And these of course, are usually musculoskeletal things like acute strain or sprain overuse injury, either from occupational or the way somebody's sitting or conducting their physical day to day life. And then I also include things like missed injuries, uh such as an annular tear or the tear in the wall of a disc, which can be very, very minute and can't be picked up on an MRI. But in the right clinical setting, such as uh lifting heavy objects or sudden twisting motions can cause searing back pain, even though you can't point to something on an MRI and say that that's that, that's the problem. And then there's this idea, this overarching idea of sensitization, which has been kind of validated through a number of different studies saying that there are definite factors such as uh lifestyle factors, psychological factors, cultural factors, these play a significant role in folks perception of their back pain and understanding of whether it will get better and modifying those factors can be a key uh adjunct to anything that I might do as a surgeon to try to help, you know, improve these patients. And so when we break down specific pain and this is something where I as a surgeon can, can really step in and help. So we, we point out several things that again, you can point to on an MRI scan and say, look, this is the cause of your problem in the upper left. Here, we have a disc herniation. This is looking at the lumbar spine and a piece of the disc here that is extruded out, the arrow is pointing to and it's pushing on nervous system structures that can cause acute back pain again, because the outside of that disc has dense nerve endings and has ruptured in spondylosis. This is a slipping of one vertebrae on the other for a number of different possible factors. Again, you can see this even if, if you're not trained to look at these MRI S or CT scans, specifically where one bone is slipping forward on the other with the degradation of the disc material in between. And you can imagine how that might cause a tremendous amount of back pain, especially if it's a very focal change that is not present at other levels. Things like compression, fractures, spinal stenosis, compression of the spinal cord here. This shows cervical cord compression uh from a herniated disc within the cervical spine here or even obvious things like a tumor within the spine. These are specific causes of pain that oftentimes in the setting of the right history, respond very, very well to surgical and even sometimes non surgical therapy. But then we get back to again many, many times what we're seeing in our offices and our clinics are not the patient with one single problem on the MRI scan that we can point to and say this is the cause of all of your problems. Those are the easier, more straightforward cases. It's these patients where we have non-specific pain or we have imaging findings that may or may not be symptomatic that are the challenges and then, and what do we do with those patients? And so this is kind of a little kind of scheme I came up with a way to really think about things. So if you take all the patients that have uh this what we call specific pain, there's a larger majority of patients that have this non-specific pain, again, we can't point to anything on an MRI scan. It tends to be acute or subacute pain, uh sometimes chronic, that's not getting better. And then we look at all the patients who might help be helped from surgery. So if you look at the overlap of all those three things. There's the bread and butter cases, patients with something we can point to on an MRI scan. We have very reliable surgical intervention for them and they're, they're likely to get better. Those are the folks we like to see in our office because we really have a way we can, we can help them very easily. There are some folks who get surgery, even though they kind of have this non-specific pain, nothing we can point to an MRI scan and they feel good. And we as a field are, you know, we kind of throw our hands up and say, well, I'm glad you were helped, but we only understand mechanistically why you were helped. And then there's the, the I think of the larger majority of patients who are the frustrated patients who don't really have anything on an MRI scan to point to. But they have, they have terrible pain. And for those folks, you know, the reality is that they don't have great options. Surgery is probably never going to help and, and present that they present a particular, you know, challenge for us. And so this is the typical scenario of somebody that comes into my office. You're looking at an MRI scan here of somebody that has multilevel degenerative disease in the lumbar spine, flattening of the discs here between the different bones leading to uh disc herniations posteriorly. This right here is the spinal canal that you're seeing in a cross section and you can see how the spinal canal is being narrowed as it goes through from these disc herniations and other degenerative changes. And this patient could be any of a number of different patients that are coming to see me. So it could be a 69 year old with very classical spinal stenosis related pain. It could be a 47 year old with just, just back pain, no radiation to the legs. It could be that 72 year old that feels absolutely fine. But somebody ordered an MRI for some other reason and, and what do we do with this patient? So the question that I'm always trying to address when I see these patients for the for the first time is ok if I'm thinking of a surgery, am I addressing the right problem? Am I just treating an MRI scan or am I really treating something on an MRI that has a correlate with what the patient uh history and examination is and then is surgery necessary right now, which is a very, very different and important question because of some of the risks that surgery that surgery poses. And so in these patients for whom they really could present any way. And all I have is an MRI with some, with some kind of non-specific non uh normal findings on them. What we're trying to do is take what might be non-specific pain and through a number of different ways, turn it into specific pain to try to say, how can I translate this into something that's going to benefit from surgery? And we have many ways of doing that. And so hopefully, you know, as a good physician, the history is where we start the exam maneuvers are where we start trying to find ways that clues that point to what exactly is symptomatic here. That includes an understanding of what the patient's activity level is like, what their function is like, what they want to get out of surgery. That's all important, how their pain has evolved over time. I myself am a big believer in partnering with our pain management team here. Um who uh and and around uh the area who do you know, great, great work and in trying to manage these patients non surgically and how patients might respond to different pain management interventions can give us an idea of what may or may not be symptomatic. Um And we use that as well in our, in our decision making. And so this is taken from New England journal paper that was looking at patients with non-specific back pain who were not really deemed to be surgical candidates, you know, what, what do we do and how they respond to different interventions. My apologies for the busy slide. But if you just look the vast majority of the studies that have come out and, and looking at this in a meta analysis type fashion, the quality of evidence is really not very good. And so we don't really have much to go on. The other thing that you'll see is that, you know, the the effect of many of these things, many of these interventions is really not, not very convincing. But again, the quality of the evidence is low. Uh One thing I point out is that spinal manipulation oftentimes done by chiropractors um really has also not been, not been shown to be uh in an evidence, evidence-based fashion to be very, very helpful. And so here we are, you know, kind of looking, I pointed at this very small percentage of patients who have, you know, non-specific pain but did get helped by surgery. You know, that's, that's the kind of patients we're trying to understand is what is it about these patients that that worked as a result of surgery? And what does that tell us about, about this non-specific back pain? There will always be patients that we cannot help, but we have to try to understand mechanistically what's going on with these folks and why surgery might or might not help. So there in there in lies the challenge. Um And so I want to get on to my next point here, which is that, you know, what, what exactly can spine surgery do? Why do we consider offering uh out uh surgery for these patients? And, and what are some of the evidence behind it or not behind it? And so I want to talk to you a little bit about why, what our experience as a field has taught us about, you know, why spine surgery might work. And so what can spine surgery do? And this, this is, you know, one of my mentors when I was going through my training kind of pointed out that, you know, what, what we do is relatively simple. It's only really three things I can either decompress uh nerves in the spine that are being compressed. I can stabilize the spine in some way by adding some sort of hardware, other uh sort of um uh device that can help stabilize the spine in certain ways. And then I can realign the spine if it's out of alignment. And again, what we're trying to address are these findings of specific pain. If there's something pressing, if there's something out of place, we can try to fix that with spine surgery. And again, if the pain matches with their symptoms often do a uh quite a successful job of that. And so let's talk about decompression. And so this is typically considered in situations where you have spinal stenosis, the patient's symptoms are consistent with like myelopathy or compression of the spinal cord or radiculopathy, you know, pain mostly in the legs greater than in the back. Uh This reflects compression of neural structures, what you're seeing on this video here, this this sort of uh you know, uh off white structure that you see right here. That's the fecal sac uh that contains the nerve roots underneath. And uh what we're doing here is kind of removing bone, removing ligament that has caused a lot of compression on the fecal sac and, and completely decompressing it and moving it, you know, very carefully under a microscope. And again, we, we typically do this uh in patients for whom we think that a neurogenic neuropathic cause of their pain is the most likely. Um So this does not typically affect back, especially because back pain as we'll discuss in a minute is, is usually not caused by compression on nerves. Although that can, that can vary in some situations. For, for example, some folks who have a ridiculed, uh the main place that they feel that ridicules is in their back or their hips. So there can be exceptions to that rule. Um but these are very successful surgeries, they're relatively well tolerated, low blood loss surgeries. And so we as neurosurgeons really like to perform and we help people a lot this way, this is looking at a slightly different form of decompression. So, what you're looking at here is this MRI where a patient now, instead of operating in the lumbar spine, we're in the cervical spine and a disc herniation has pressed backwards on the spinal cord and compressing the spinal cord. And what you're seeing down here is that disc being completely removed, all the compression taken off of the spinal cord. Again, here's that disc being removed and some drilling away and then we can't just leave that disc out. So, inevitably, what we do is we replace it with a fusion device. And so this is an A CD F or anterior cervical discectomy infusion, which is, I'm sure a procedure that many, many of your patients have had before. And the reason we do this is because in the, in the cervical and thoracic spine, we don't have spinal nerves, we have the spinal cord. And so we have to do other maneuvers to try to maneuver around the spinal cord. We cannot retract on it or do anything else that might endanger neurological function. Again, these are well tolerated, lower risk operations in well selected patients. And if we look at sort of the evidence, this is uh done by the group uh at Hopkins, uh looking at just after lumbar laminectomy, probably the most straightforward procedure that neurosurgeons do in the spine. Looking on the left here, these are looking at different symptoms that patients might present with uh the taller bars here being uh preoperative and the shorter bars being post-operative. And you see a substantial majority of patients, those symptoms do improve. But then if you look at the flip side on the right, you see uh essentially a Kaplan Meyer curve of folks progressing towards needing reoperation. And when you look at 10, around 10 years after uh the surgery in this cohort up to about a quarter of the, of the patients, about 25% of patients required some sort of reoperation. And so this gets to the idea that we'll address a little bit more later on, which is that spine surgery is usually never a one and done that by doing something in the spine, we are changing somehow the way the spine works and it's up to us and working with you all to discuss with the patient about, is it worth that particular risk based on the symptoms? The patient has continued to experience at that point in time. So again, going back to what can spine surgery do? We've talked about decompression and then we'll talk about, I think a more contentious thing which is stabilizing the spine. And here's where we get into spine fusion, which is, uh I think something that's become a little bit more hotly debated as of late. And what we talk about with stabilizing the spine. Again, the, the one of the essential functions of the spine is for, uh to put it quite simply keep you standing straight up. And that's a much harder, uh harder task than, than one might realize the spine has to be in perfect alignment with these gentle sort of curves which place the top of the spine, the cervical spine directly above the lumbar spine and above the hips, keeping your neck, above your, above your legs and keeping you from constantly pitching forward or pitching backward as you attempt to stabilize yourself. There's a number of different paraspinous muscles we all learned in the anatomy lab, which provide uh a not insignificant amount of support as well to the bony structures. And then again, the idea of this functional spinal unit, with all of these more uh miniature structures at the individual spinal level, offering stability to those individual spinal levels. And then the number of spinal levels contributing to the global balance of the entire spine. And so when this gets out of whack is when we start to see symptoms that develop from that. And so as we get older, the aging of the spine essentially is a disease of chronic instability. All of those things that aim to hold the spine together, the set joint, the disc spaces, uh the bones themselves start to become deranged. And so when you see things on an MRI scan report such as facet arthropathy or a deformed facet joint disc kite loss such as a collapsed disc here, bridging osteophyte formation. These are all these all reflect that the spine at that particular level is developing microscopic instability and in some ways attempting to compensate for it to help to keep their that that person standing straight up with a minimal amount of pain. The problem is over time, those things are also gonna lose their ability to compensate. And so there's a complex interaction between everything that's going on within the spine as well as trauma, for instance, a fall that might result from anything else. Uh The medical history of the patient, something like osteoporosis plays heavily into this and external factors such as occupational risk factors all play into the degree to which and the speed to which these things degenerate. And of course, as we have seen, it's a sliding scale of severity and what we see on an MRI scan, all these changes that you see may not relate directly to the symptoms or the function that the patient is having. And so again, on a path of physiologic level, what we're looking at is chronic instability and how much chronic instability is a perennial question when you get to things like this, like we've talked about spondylosis where the spine is slipping forward or a compression fracture where the spine is literally crushed. You know, these are somewhat obvious cases of instability. We can see the spine slipping, we can see it moving, we can see that the align of the spine has been changed by this compression fracture. And basically the supporting structures are incompetent, they cannot stabilize the spine anymore. What surgical fixation does is allows us to recreate the stability of the spine at that particular level. And so that's why you usually see in this case, patients and with surgical hardware. So in this case, a a device has been placed between the two bones in the inner disal space, fusing those two levels together. Uh This one, the fusion was done from the back. So we've placed rods and screws above and below where the patient had a fracture. Again. In order to eliminate the symptoms that arise from that level being unstable, the instability is what leads to back pain. As the bones slide on themselves, the nerves which are in between the bones can also get crushed and that can lead to neurogenic neuropathic pain as well. And so, in many of these cases, in addition to stabilizing the spine, we're also decompressing the spine. And in the long term, our goal is not just to put these hardware devices in place, it's to have the patients grow bone in and around those hardware devices to offer a long term fusion uh to this problem. But again, those are the obvious cases, what we mostly see are things that are not obvious. So these are some of the other findings that you might read about on an MRI report, things like fluid in the facet synovial cyst generated within the spine, interspinous fluid facet joint hypertrophy. These also reflect we think instability within the spine, but just not on a level that is so obvious that we're seeing things slipping and sliding all over each other at this point. So things that are unstable on an MRI scan are not always clearly defined, they don't always cause symptoms, right? A number of patients uh when we get to a certain age are going to have changes like this on an MRI and most importantly, just cause you see changes like that, it does not mean that surgery is the necessary. Next step, this really became a hotly discussed item in the, in the literature here over the course of the last few years. So a number of high profile trials in New England Journal were uh were performed. This is looking at one trial for instance in Sweden where basically they were able to uh look at these patients who had either spinal stenosis or low grade spon, the which is slipping of the bones on each other and say, OK, you know, we have these, these patients that have back pain and or leg pain just purely from a mechanistic standpoint, what do we get by adding fusion versus just doing a decompression to those patients? So again, randomizing patients to getting just a decompression or getting a decompression plus a fusion trying to boil down to in the in the patient that there's clinical equipoise for one way or the other. What exactly on a mechanistic level does a fusion get you? And what you can see by looking at this is that I've highlighted just the patient satisfaction score, but this was true for all the disability scores that they, that they mentioned there really was no significant difference, there was a significant difference looking at things like operating time and the amount of bleeding when you added a fusion surgery. And that's just because those are more invasive surgeries. And they concluded that decompression plus effusion did not result in better clinical outcomes. And of course, this was surprising for, for all of us. But again, this is randomized data that we're looking at another study published around the same time, looked at if somebody had that little bit of slipping, that little bit of spal thesis, again, what do we gain by adding a fusion to a decompression in those patients? And what this shows here is that basically, if we, if you look at a measure of disability, the OD I, there was not a huge difference between patients who did or did not have a fusion. And more importantly, uh a large number of these patients in both groups went on to require more surgery at some point uh over the course of follow up, uh the decompression alone group seemed to poten potentially need uh more surgery, but this did not reach statistical significance. And so basically, they said that, uh, you know, an overall value assessment, if you look at how much more expensive adding a fusion surgery is, and the recovery that goes along with that, we might be better off by just doing laminectomies alone in these patients and sort of watching them over a period of time. And so, you know, this has led to a number of different folks kind of putting the hammer down on those of us who do spine fusion surgery and saying, you know, what are we actually doing here? Uh You know, how do we reconcile this? We have randomized data that's basically showing that you guys should not be putting all this hardware in people. And I think part of that is probably true. You know, anybody who's involved in the care of these patients has seen folks who got worse after a spine fusion surgery then then got better. Um And, and so that's still a challenge that faces us. And we as a field have struggled to, to deal with this for a little while and we're actively trying to generate the right studies to, to, to study this a little bit better. The problem is that we know in clinical practice, we see folks who have had surgery fairly recently or even as few as 5 to 7 years ago, coming back to see us for needing another operation, which inevitably turns into a bigger operation, more complex operation with a slightly higher risk, uh or in many cases, a much higher risk of complication. And so we understand that yes, there is a downside to, to fusion and cost and complications for these patients. But at the same time, the randomized data that exists was not really powered to detect the differences in reoperation for these folks. And so there's some sort ongoing discrepancy between, you know, the trial results in our experience and, and we have to try to understand this balance a little bit better about what are we gaining or losing by adding a fusion for, for these folks. And so, you know, we, we have these different scenarios where somebody might benefit from an operation, but we do not yet fully understand what exactly is driving the disability when we see an abnormality on an MRI scan and then why exactly a patient might or might not improve. And for what length of time. So there we probably have not identified the exact right population of patients who would I who would benefit from a fusion, but that population of patients we're convinced uh exists. So that's if if anybody talks to you or mentions that to you, you know, that's, that's kind of our engagement with, with the data at this point. So the last thing that spine surgery can do is realign and I I'll just touch on this because I think it's, it's less germane to the group here. But uh just to show you that those same things that we see in the aging process of the spine that happen at individual levels within the spine also cause problems within the entire spine and the balance of the entire spine. Remember I told you that normally we want the neck to be held in alignment over the hips and that gen generates stability and the ability to walk up straight without being pitched forward with time, the uh the aging process makes that less effective to where uh the general uh pattern is the head slipping forward over the spine, what we call kosis and patients driving further and further forward. And historically, you know, understanding all these parameters and measuring what happens to folks. It used to be the domain of scoliosis surgery, basically surgeons that were fixing, you know, very dramatic curves in folk spines, huge curves that you can see obviously. But now as, as we as a field are evolving and trying to understand why patients might or might not do well with surgery, we're applying these principles to more common degenerative operations. So for instance, you know, this is what we typically think of a patient with a very uh you know, scoliotic spine, an imbalanced curve uh that's corrected with this large fusion operation and trying to bring them back in alignment. Yes, we know that's a, that's a large operation, not every patient needs that operation, but it also is more applicable in something like this. So on the left here, you see a patient who has had a small operation down in the low part of their spine, but has developed something we call a flat back deformity where the low part of their spine is basically completely flat up and down, they cannot keep their head directly over their hips without bending their knees a little bit. And so this patient is probably chronically pitched forward, sort of looking at the ground, unable to stand up straight wondering why, you know, they cannot get the mobility that they're hoping for. And so we as a field have grown to understand that without going into too much detail in ways that, you know, we can correct the alignment a little bit better by doing these multilevel fusion operations. And we have found at least in the data that we have so far that not only are we increasing the effectiveness of the operation, but in the long term, decreasing, the need for these patients to undergo more surgery. And so we think that a lot of the failures that we used to have with these patients who are a failure to understand the mechanics of the global spine on this level. So we're still understanding the long term outcomes and, and whether doing a big surgery like this is really worth it. Um And for whom it might be worth it. But uh just know that, that uh that's a growing area of understanding and if you see patients that are having these sort of longer segment spine surgeries, that, that that's probably a reason why is we're actually trying to avoid them needing further surgery uh in the future. So moving on a little bit more, I, I wanna talk a little bit more about the flip side of the coin, which is where uh those of you on the non surgery side can, can help us and, and help us to maximize uh the outcomes for these patients and uh, and how well they, they can do with these operations. And, and I don't, you know, II I say this not as a triviality, this is truly, I believe an essential part to uh to patients thriving um with spine surgery. And again, you know, when I, when I see folks in the office, this is the immediate thing that I'm trying to understand, am I addressing the right problem? You know, and what I see and what I'm seeing on the MRI is that reporting is going along with the symptoms and the examination and then is surgery necessary right now. And I say that to you because I think these are questions that you can start to think about if you, if you see a patient that has chronic pain or you're thinking might need the services of a surgeon, you know, these, these are things that you can help us. Definitely to, to answer the other thing that I uh think about is not only do I want this patient to have a good immediate result right after the surgery, but especially in younger and younger patients that we're seeing for spine surgery, will they have a good long term result? Am I gonna do something but just potentially set them up for problems? 1015 years down the road? Uh, you know, that's a very other important aspect of the of the care here. And so going back to this kind of schema that we had before, again, the specific pain is where surgery enters the picture. I'm gonna sort of wipe that out for now because we've talked about it and draw a little bit more attention to the kind of non-specific pain and the sensitization factors. Um, which is what you all I think are going to see and deal with more on the non surgery side of things. And I want to address the idea of, of you all being, you know, partners with us and uh and trying to, to get the best outcome for these patients. This is one of the guidelines that was uh that was published here for, you know, practice of patients with non-specific low back pain. And I was, you know, I'm always surprised to see that one of the, you know, high grade recommendations is that you do uh or anybody does intensive patient education and that actively educating the patient on what to do and what not to do, but also what can be expected in terms of improvement from the non surgical intervention that's going to be provided, whether it's handouts, whether it's 1 to 1 education, this has a tangible impact in terms of improving the perception of pain and the quality of life for these patients in the long term. So it is uh similar to the idea that, you know, the more times you mention smoking cessation to a patient increases their odds of quitting. Uh, it's almost, uh, seem similar in my mind that the more you educate folks about the idea of, uh, uh, you know, the multiple different pain generators in the back and what can be done, uh, the more helpful it will be for their long term outcomes. But really, you know, what, what goes into the decision to pursue spine surgery and pursue referral to a spine surgeon is an understanding of the medical risk that goes into the surgery, understanding of the social risk. For instance, social support, the ability to afford the rehab and the other things that go along with it, the family structure that goes into recovering from a large spine surgery. These things are as important as a surgical technique themselves. And then really the non surgery factors that I find influence the success of surgery, the most are going to be how prepared are patients for what they are going to go through. I really believe that we need to have a strong amount of buy in from any of the patients that are undergoing these surgeries. Uh I don't offer surgery to patients if I don't feel that they have a great understanding of what they've been through already where surgery fits into the treatment paradigm, whether they have unrealistic expectations about what surgery can do and whether they're willing to put in the work that it takes to recover from a large spine surgery. These things are, are key uh to, to the success of surgery. And I think that, you know, you all can help us to start with that coaching and help to understand. I've had so many patients where I wish, you know, before I had done surgery that I, I had a chance to speak to the primary care provider about, you know, what, what is your gestalt about this patient? Is this a patient who responds well to what you tell them? Is this somebody who's going to get better? Because honestly, somebody who knows the patient better than I do is going to be in a better position to answer that. And so I think even if it's just as simple as sending us a quick note or a phone call or a message in, in epic to just say, you know, I'm sending you this referral, but here's what I, what I think about this patient. It, it just goes a very, very long way. These are some sort of things that you could potentially discuss with the patient. I mean, I find a very good starting point for discussion is, you know, what have you heard about spine surgery? And that tends to elicit a lot of strong opinions from folks. Um, and then, you know, you can start to kind of modify those opinions or you can start to get a sense of where folks are and their decision making about that. And then these are some of the other questions that I kinda go in to folks in particular, you know, what activities are important to you. What do you want to be able to do? And then can surgery get you there or not get you there? Um, and so I encourage you to, to broach this topic and discuss that with patients because you'd be surprised at the number of, uh, things that, that will tell you to where you could say, I don't even know if it's worth it for you to pursue, you know, spine surgery at this point. And again, you know, we recognize that these are the two kinds of patients that are gonna walk into the clinic, folks who have debilitating pain, but not necessarily anything that's, that's going on, um, on their MRI scan. These are the folks who you can help us to understand better. You know, what, why do you think this person might be having 10 out of 10 pain? Do they have psychosocial stressors? Do they have something else that might be driving what's going on? Um, and we can use, can use your help for that. I want to talk about a few can't miss spinal conditions. Um, these are things that I, I think could be easily uh identifiable uh in the primary care setting and, um, can you can draw our attention to them. So one of them I think is cervical myelopathy. This is generally from cord compression within the cervical or sometimes the thoracic spine. And it usually manifests uh neck pain may be not, may or may not be there but radiating pain into the hands and arms. And unlike something like carpal tunnel syndrome, for instance, they can really develop profound weakness as well as stiffness. And you also see these gate changes. What you're seeing in this gentleman here is what we call a spastic gate and ability to, you know, place 1 ft properly in front of the other. It can be something that's more obvious like this or it can be something as simple as inability to do like a tandem gate, like a heel to toe gate on examination. And so, uh, if you see somebody with neck pain, but then some of these other symptoms, that might be a clue that uh, myelopathy is present. Coquina syndrome is something that I know a lot of folks hear about. You know, I'll be very honest when many folks fear Coquina syndrome, I'm, uh very appropriately uncalled, but the vast majority of the time, it's not that, um, and I understand it's a condition you don't want to miss the, the clues that go in with that are not only is it severe pain, like pain in the back, one or both legs, but along with that sacral nerve dysfunction. And that's why we talk about saddle anesthesia. That's why we talk about in particular urinary retention. So, an inability to, to initiate a urine stream or evidence of urinary retention on exam, uh such as overflow incontinence. I I oftentimes ask patients when you wipe after going to the bathroom, does it feel normal? That's probably a good question to sort of elicit symptoms of saddle anesthesia, um, rectal exam, you could, you could perform that. But honestly, the inter rater reliability of of a rectal exam is pretty low. And so I think these questions kind of get that much more commonly. What you're seeing on this picture here is, is a surgeon pulling out a a very large disc herniation that was causing Co aqui syndrome as is usually the case. And then I I said this is not typically, I think thought uh taught in, in sort of primary care settings. But uh I think that recognizing thoracic myelopathy and radiculopathy is very important. So, uh the distinction between thoracic and cervical myelopathy is that uh traditionally cervical myelopathy will involve the hands and the legs. Thoracic will only involve the legs and oftentimes you'll also get thoracic ridicules. So not only is the spinal cord being compressed by whatever is going on, but also the nerve roots creating pain that radiates from the back around to the front and sort of almost like a shingles like distribution because that's, that's essentially what's going on. The nerve root in that area is being compressed. And the reason why I think recognizing thoracic myelopathy or radiculopathy is so important is that the vast majority of conditions like spinal infections and spinal tumors present within the thoracic spine. So tho those may be the first clue um to something very serious such as a spinal tumor uh that's happening. And so I would encourage you to bring those cases to our attention if you do see them. And so how, how can you all help us? Well, II I and I understand the, the pressures on time that face uh folks in the primary care office, but as much as you're able to check your own neuro exam, including mobility, uh that gives us a great benefit in terms of understanding what the functional limitations for somebody are. And um you know, if any of those quite obvious uh findings might be present on examination, uh maximize the educational resources again, going a long way in terms of helping us understand who might benefit from spine surgery, talk to patients about smoking and weight loss, uh which oftentimes will be uh exclusion factors for spine surgery as I'll discuss in a moment. And then, you know, I'll, I'll say, consider the long term potential for recovery. And again, this is something that a primary care uh doctor uh or somebody working in that setting is likely to understand better than uh subspecialist might, which is, you know, you, but you know, better than anyone. Is this somebody who's going to be able to go the distance in terms of recovering from the surgery and, and getting your gestalt on that, uh, can be very, very helpful. Um, I'll go into this in just a moment one more time. So the last thing I want to talk about in the few minutes that we have left is what can't spine surgery do. And I wanna use our way into this as sort of talking about what are some of the risks of spine surgery which are, are rare, but of course, can be serious. And, and this is what I like to tell patients. And admittedly this is somewhat dramatic, uh, to say that spine surgery is always a step backward. But I, I say that because there is no spine surgery that I think can be done without compromise. When you, whenever we do spine surgery, we are inevitably changing the way the spine works. We are doing something that might affect the long term balance of the spine. We might increase the need for another operation in the future. Uh, we might place an undue social burden on somebody because of the recovery that's involved. Uh, so it, it has to be, has to be taken seriously. And so, um, I, I kind of, I say this again somewhat, somewhat dramatically, not because I don't believe in what we can do. But I want to relay that, uh, that to people and, you know, a successful spine fusion. And I'm, I'm using the word fusion here. But really interchange with surgery in general, there's multiple different things that have to happen. So, of course, the surgery has to happen without complications. The hardware has to be well placed and that's the sort of immediate, uh, you know, thing that we know right after surgery, no per operative complications such as DVTs, infections, UTIs, uh, those sorts of things which we know in the days to weeks after an operation and are definite risks of spine operations. And then there's the longer term where most failures that are gonna happen in spine surgery are gonna happen here, which is that be fusion does not happen. So we've placed hardware, but the patient does not grow bone in and around that hardware and then they develop adjacent segment changes or changes that other levels that have not been operated on, uh which happened years down the road and might need more surgical intervention at some point in the future. And so we need to understand that what are the patient's individual risks for all those things happening or not happening uh within the surgery themselves. Spine surgeries have the potential for several liters of blood loss, intraoperative fluid shifts. The other issues that you see there, I think this goes kind of without saying that uh patients who are higher risk for other surgeries are going to be a risk for spine surgery as well. And these are common reasons why somebody might not have spine surgery recommended you know, uh, some of the more frustrating ones that folks come to me with are, uh, if patients are very heavy. So BM I of greater than 35 the data tells us if they're active smokers, you know, these patients are the ones who tend to have a lot of pain and I want to show you why those might be exclusion factors for, for surgery. Um, so for example, these are just some complications that might result. This is looking at placement of a, of a screw within the pedicle and just looking at different ways that the screw can be misplaced. So in particular, if you look at this one, the screw in this case has been placed but has gone through the spinal canal, placing the spinal cord at risk. So that's an immediate complication that may happen in surgery. We of course have uh you know, ways of avoiding that, but that's certainly a risk. This is looking at um complications of placing hardware. So on the left here, you have somebody has had a spine, uh the cervical fusion, but the hardware has started to pull out. You can see the bones are starting to crumble away. We see this commonly in folks who have osteoporosis or folks who are, have a history of smoking, both of which inhibit the bone's ability to really heal together. There are technical factors that go into this as well. But um smoking and, and uh osteoporosis are definite risks having this happen. This buys the patient another surgery that's almost inevitably another massive surgery on the right here. You see the sort of darkening around the screws, evidence that the screws are pulling out of the spine again. Uh This is something that happens down the road after successful surgery. And this is why we, we take those comorbidities, uh so important because if something like this happens, it buys the patient another bigger surgery. This is the idea of pseudarthrosis. So this patient has had a spine fusion here at L five and S one. And what you can see this line here that runs through here is that the patient has not completely put bone in and around the hardware that we put in. And this can uh there's an emergent risk factors for this. But uh this is something again can lead to more the need for more surgery down the road. And this is all in addition to the other risks that we know go with spine surgery, blood loss, the risk of spinal fluid leak, the risk of nerve injury, uh of paralysis. Those things always exist. Um Hopefully not at higher rates than the technically competent surgeon. But these are the things that are unspoken that we're always in the back of our mind when we see a patient and trying to address their individual risk factors. So the reason why thinking about all of that is important is because again, going back to this, this diagram, we're trying to avoid operating on the most difficult patient, which is a patient with non-specific pain for whom surgery is probably not going to help. And, you know, those are the folks for whom a, a complication, uh, is, is doubly worse. Not only do you have, uh, the, the, you know, things that come along with a complication, but you have the fact that the patient didn't get treated for the right reasons and, and never really had improvement in their pain. And so this gets the idea of what can't spine surgery. Do you know, what are the things that I see that I just say, you know, the benefits of, of doing my surgery are not going to be worth it. And the first thing is improving non-specific pain. So if we are unable to take that non-specific pain from a particular patient and somehow turn it into specific pain, somehow find a generator for that pain. Patients are less likely to get better with surgery. Fortunately, that is a huge number of patients for whom we can't find that. Um, but it's just not worth it to pursue spine surgery and some of the risks that come with it. In that particular case, we cannot fix nerves that have already been decompressed. And I'll talk to you about, you know, some situations like that in the mean, in a, in a minute, I wanna really point out the last thing here, which is that we cannot restore function when there is no functional deficit. So, if you have the, the, uh, you know, asymptomatic, 70 year old that comes in with significant stenosis on an MRI. But they're walking, they're doing the things that they like to do. I can't make that patient better. And so it's hard for me to justify doing a spine surgery. I think that's very important to, uh, to keep in mind when it especially comes to, to older patients. This is the condition uh that we see on a weekly basis here in the office, it's called spinal oitis where somebody has had some sort of spine manipulation, maybe epidural anesthetic in the course of childbirth and the nerve roots have sort of clumped together into a single uh larger structure that you see there due to scarring of the the structures around the nerve root. And these nerves have been well decompressed. And these patients get sent to me because they have pain that is associated with this. They have pain in the back or the legs. I surgically cannot do much about this. You know, we have to turn to non surgical treatments or perhaps things like spinal cord stimulators and pumps to to be effective. Similarly, there's this idea of post laminectomy syndrome. I showed you the slide earlier where somebody had an excellent anatomical result where the spine, the nerves were very well decompressed the results of surgery but they still have substantial back pain, they still have substantial leg pain where I anatomically cannot point to anything on an MRI that I can do to make that better. And this is the idea of post Laminectomy syndrome, which is very real but, but poorly understood. Um And so we have to go to other things to try to make that better. And so we get to, you know, well, what are the options? If you see one of these difficult patients in your office, what are, what are the options? And again, as a surgeon, if we cannot identify a pain generator surgery is unlikely to be successful. We have to keep in mind that there are non anatomical causes of back pain and that gets to everything we have talked about before with um, you know, those sensitizers to pain, things like muscle sprain and strain those kinds of things. They cause very, very real pain. I cannot fix those with, with surgery. And similarly for the, the healthy person without, without symptoms. Uh But with a terrible looking MRI scan, it's, it's tough for me to make that, to make that patient better. And so what do we end up leaning on in cases where surgery can't really be offered where I would, I, I would say it's sort of a combination of all of the above. It has to be a combination of non surgical pain management. So, doing the best we can with medication based therapies, the expertise of our pain management specialist who can help with things like pumps, stimulators, uh epidural steroid injections, uh to try to get patients some, uh, even if it's not 100% relief. Um, and then the things on the bottom are just as important. Things like constant education and expectation settings for folks telling them that we may not be able to get you 100% of the way. But by attacking this problem on several different non-surgical fronts, we can hopefully improve your uh your function by 40 50% and getting them to understand that that might be the best realistic expectation for that along with serially reassessing these patients to make sure they're not addressing that they're not developing any other signs or symptoms, which might be a clue to a specific pain generator that's going on for them. So it, it is, I certainly recognize frustrating to have to deal with these folks. But um I think it would probably be more frustrating to have to deal with an unwanted spine surgery complication. And so again, I end with that, that statement that I, I tell folks again, uh somewhat overly dramatic, but I think important, important to keep in mind. Um So I wanted to leave some time here for questions and I just say a few things in summary, again, the majority of acute and chronic back pain is not surgical. Um and uh reminding our patients of that often. Uh I think would be very helpful. Uh We as surgeons need to learn more about the biomechanics, the benefits and pitfalls as well, fusion surgery. But we are confident we know that it works and through uh doing it and studying our outcomes in a very rigorous way, we can help to refine and better understand the patients who would benefit. Um, non surgeons have an essential role to play and we've kind of talked about what your role in that might be. Um And then, uh lastly, we need to aggressively validate the benefits of what we're doing because uh the risks are, are not inconsequential. Um And with that, I'll uh remind you again of our services here at uh at Christian Hospital. And uh thank you very much for your attention. I'm happy to uh, to take any questions that you might have. Created by Presenters Kumar Vasudevan, MD Assistant Professor of Neurosurgery View full profile
