Spine Surgery 101

MemorialCare Health System, excellence in healthcare, presents Weekly Dose of Wellness. Here's your host, Deborah Howell.

Deborah Howell (Host): Hello. Welcome, welcome. You are listening to Weekly Dose of Wellness. It's brought to you by MemorialCare Health System. Here we go. I'm Deborah Howell. Today our guest is board-certified spine surgeon Dr. Bryce Johnson, chief of surgery at Saddleback Memorial. After earning his medical degree at the University of Pittsburgh School of Medicine, he completed his orthopedic surgery residency at Northwestern University, where he was elected as chief administrative resident. Dr. Johnson specializes in both open and minimally invasive spinal surgery. Today's topic is Spine Surgery 101, The Very Basics. Welcome, Dr. Johnson.

Bryce Johnson, MD: Thank you for having me.

Deborah Howell (Host): Let's get into it. Maybe you could describe the various parts of the spine for us.

Bryce Johnson, MD: Yeah, essentially there are three parts to the spine. So you've got your cervical spine, which is your neck, your thoracic spine, which is your mid-back, and then the lumbar spine, which is your lower back.

Deborah Howell (Host): What are the major causes of back pain?

Bryce Johnson, MD: So the most common causes of back pain are actually your sprains or your strains, and then your degenerative conditions. So things such as stenosis, herniated discs, slipped vertebrae, which we also call spondylolisthesis. And the far majority of causes are actually just your sprains or your strains. So your cervical whiplash or your lower back strain. These by far are the most common conditions that people will suffer from.

Deborah Howell (Host): I heard something crazy. This is a little off topic about texting, that when you bend down your neck to text, it's as if you're putting 60 pounds of pressure. Is that possible?

Bryce Johnson, MD: It is. I mean, a lot of the things we actually do is not very good for our neck. So driving a car here in Southern California, we drive continuously and the neck and back really suffer. In fact, a lot of times patients won't even notice how bad roads are or how bumpy their car is until they have a neck or back problem and that constant vibration will irritate things. Driving, holding your head in that steady position, going to the movie theaters or now texting or computer use. We're all sitting at our computers or watching our televisions. Those put a lot of strain on our necks especially and of course sitting really puts a lot of strain on your lower back. I don't know the exact number, but I wouldn't be surprised that texting - holding your neck in that position would put you at quite a bit of stress in the neck.

Deborah Howell (Host): Amazing. Just sitting there driving? Really?

Bryce Johnson, MD: Yeah. Yeah, just holding your head in kind of a constant position. It can definitely put some strain, or movie theaters looking up, having your computer screen, you know most of us know that if we don't have that at the right level that can put a lot of strain on our necks also.

Deborah Howell (Host): Unbelievable. Okay let's get into this next part of the topic of consideration. Before patients take a look at surgery what else can they try to alleviate back pain?

Bryce Johnson, MD: Well, the good thing is that the majority of patients actually will never get to the point where they need surgery. So most of the time what we're talking about right now is actually going to take care of their problems. So starting off simply with rest, ice, kind of some common sense sort of things, most of the time patients will improve, especially when it's a strain or a sprain. A lot of time modifying your activities. So are you doing a lot of lifting or bending or twisting, those sorts of things, minimizing or eliminating those can really help. The next step would then be moving on to medication, so anti-inflammatory medications, your Advil, Aleve, Motrin, things that will both address the pain and the major cause, which is the inflammation.

Deborah Howell (Host): Okay.

Bryce Johnson, MD: Then from a medical standpoint, we get into things such as physical therapy, sometimes chiropractic care, acupuncture. The idea there, too, is to decrease the inflammation, the irritation, the therapy also can be very beneficial long-term. So stretching, strengthening exercises, keeping for your lower back, your core, which is your stomach, your back, public stabilizing muscles stronger, keeping your neck muscles, your periscapular muscles, which are the ones around your shoulder strong, can help reduce the risk of neck problems. And for patients from a kind of management side of things once they're feeling better. Things like yoga and Pilates are actually great exercises for your lower back to keep it as strong as possible. When all these fail, then patients also will have epidural steroid injections as an option. The idea there is a dose of an anti-inflammatory medication, a steroid, right around a specific nerve or nerves to try and decrease the inflammation and irritation.

Deborah Howell (Host): Okay, and also Botox as well.

Bryce Johnson, MD: Correct. Botox can be used especially in neck pain when patients are resistant to a lot of these other treatments. And it works very well, especially for the spasm component. And there is some risk associated with it, which I think really places it down the line in terms of the treatment options, but certainly can be helpful.

Deborah Howell (Host): Okay. So what are the symptoms then that prompt surgery and where do individuals actually feel the pain? Okay.

Bryce Johnson, MD: Well, the best pain that is addressed surgically is the radiating pain. So as opposed to neck and back pain, which are treated surgically, it's typically your symptoms that are radiating or shooting down your arm, shooting down your leg. So kind of your classic sciatica type symptoms as patients will say. Typically the symptoms are disabling. They're impacting someone's lifestyle. And obviously the far majority of the time this is after patients have failed some degree of conservative or non-operative management. In other words, a patient has one week's worth of radiating leg pain surgery is probably not going to be the best option, with the only caveat being if someone has severe neurological symptoms. And that is, once again, because most patients will improve with conservative treatment. And if we can improve someone conservatively or non-operatively, they're always going to be better off, minus some of the red flags, so neurological weakness, severe weakness, bowel or bladder control issues, other signs that would be concerning of tumors, infections like fevers, chills, night sweats. Those sorts of red flags, as we call them, may kind of fast-track someone to surgery because in those cases, surgery is just going to be far and away a better option. But the majority of patients don't ever get to that point.

Deborah Howell (Host): Okay. So who are the primary candidates then for surgery?

Bryce Johnson, MD: So the primary candidates are people who are going to have symptoms, as we just discussed. They're going to have failed conservative management, typically a couple months worth of conservative management. Most of these will improve prior to that. But they continue after the conservative management to continue to have disabling pain, continue to have disabling symptoms. And then these are, for the most part, elective surgeries, meaning the patients can't have significant medical comorbidities. They have significant other medical problems, such as bad heart disease, bad lung or pulmonary disease, then surgery is not a good option because you may be able to treat their back or you may be able to treat their neck, but the risk of having a medical problem afterwards is so high that it makes, an elective surgery, not a good idea because overall what we're trying to do is treat the overall patient. Overall, the patient's going to be worse off afterwards.

Deborah Howell (Host): That's too bad. That's really too bad. So what happens if patients ignore the warning signs or if the symptoms are not addressed at all?

Bryce Johnson, MD: Well, most of the time, it is going to be that the patient is going to get worse. So neurologically, certainly we are dealing with nerves, we're dealing with the spine, and there are a small group of people, only a couple percent, that will have some degree of neurological problems, such as weakness, bowel or bladder problems that come about because they don't address their symptoms. But the majority of the time what it's going to be is patients just continue to worsen. They continue to have more symptoms. They continue to be more inhibited in terms of what they can do in their lifestyle. So they can't do what they want to do. They can't do what they like to do. They have trouble going to work. They have trouble carrying on just their daily activities so that it makes it as if they're not even living life.

Deborah Howell (Host): Right. And they certainly can't go golfing or play tennis or even swimming.

Bryce Johnson, MD: Correct. Correct. Or out here surfing.

Deborah Howell (Host): Or out here surfing, not to mention breakdancing. All right, so what are the surgical treatment options? There's so many options out there these days.

Bryce Johnson, MD: Correct, there are. And those options range from the very small, minimally invasive procedures to large, multilevel fusion. The biggest, most important thing, and this is going to sound somewhat obvious when I say it, but is to address what you think the pathology is. Now, that's important in all of medicine. It's really important in spine surgery. The reason it's very important in spine surgery is many patients will have more than one abnormality on their image study. So a lot of patients will have abnormalities that may have no symptoms whatsoever or even minimal symptoms from other pathology. And it's very important then to identify and address what is felt to be the main pathology. And that may allow you to do something more limited to address the majority of the patient's symptoms. Sometimes it doesn't. Sometimes there's more than one problem. Sometimes the problems can't be completely differentiated. And so determining that is going to be the main thing you need to do to ensure success. Then from there, you have a range of options, as you had mentioned. That can go from a simple discectomy for a herniated disc up to a multi-level fusion, depending on what the patient's symptoms are, depending on what their overall condition is. So, for instance, a patient with a herniated disc would be very well treated by just a simple microdiscectomy and a lot of times won't need anything more than that. A patient who has some degree of instability, so a spondylolisthesis or a slip of one vertebrae on the other, is likely going to need a fusion in addition to that because they're likely to get worse if you do something just like a simple decompression or a simple discectomy.

Deborah Howell (Host): Right.

Bryce Johnson, MD: So as I mentioned, it seems obvious, but it really is very, very important in the spine to identify what your pathology is, what your problem is, what the symptoms are that you're trying to treat and what the symptoms are that the patient needs and wants to have treated, and then addressing that with the appropriate surgical options.

Deborah Howell (Host): So if you're having any symptoms that we've discussed, please go to your doctor and that doctor will then determine if you need to go to a specialist.

Bryce Johnson, MD: Correct. Correct.

Deborah Howell (Host): And I have time for one more question. How is the recovery process for the patient in a minimally invasive surgery?

Bryce Johnson, MD: Well, so one of the big advantages of the minimally invasive surgery is a faster recovery. So as we've seen in a lot of different surgical procedures over the years, the idea is how can we minimize soft tissue disruption and collateral damage, if you will, to get the job done that we need to do. And so in minimally invasive surgery, a simple discectomy, patients can be back to themselves within two to four weeks. And with an infusion, usually it's six to eight weeks versus more traditional fusions that can be months. So patients get to more quickly return to their regular lifestyle, get more quickly to return to work. And then with minimally invasive surgeries, what we're also finding is that long-term, some of the problems, such as adjacent segment degeneration, so the areas above or below that we're breaking down and giving patients problems, actually may be lessened. So with minimally invasive procedures, we may have not only a short-term quicker recovery, but we may actually have some longer-term benefits also where adjacent levels aren't going to break down. Everyone's heard of the spine patient who's had one fusion only to come back to need a second and third.

Deborah Howell (Host): Yes, yes.

Bryce Johnson, MD: We may be able to minimize that in patients so that long-term they can actually have better recovery or at least lesser chance of having more problems.

Deborah Howell (Host): That is awesome. Thank you so much, Dr. Johnson, for spending time with us this afternoon.

Bryce Johnson, MD: Thank you very much for having me. I really appreciate it.

Deborah Howell (Host): It's been great to have you on the program. To listen to the podcast or for more info, Please visit memorialcare.org. That's memorialcare.org. I'm Deborah Howell. Join us again next time as we explore another weekly dose of wellness brought to you by MemorialCare Health System. And have yourself a fantastic spine-tangling day.