!  There are some things no back patient should ever do, but patients (and some soon-to-be patients) tend to try harmful activities every year anyway…So, how many are you guilty of?

1.   Shovel snow.  
This is one of the toughest activities any home-owner ever takes on, but every spring we get one last blast that blocks the walk or driveway, and - all across the Mid-West - back patients reach for that shovel.  If you've had recent back surgery, or you have a bad back for any reason, this is a job to avoid!  Forever!  

And if you absolutely have to move some snow, do it like your feeding a chipmunk - little, tiny bites, handled gently.
 
Snow is light when it's falling, but it gets very heavy when it hits the ground, particularly in spring when it tends to be wetter and denser.  And that snow shovel is a big clumsy spoon, designed to pick up a lot of material at once.  So each full shovel-full can easily exceed 20 lbs, which you're trying to pick up at an awkward angle while you're bending over, in the cold!  It will only take three or four big heaves to strain your back muscles and send you into spasm, so take little 1/3 shovels full, move them by stepping, not throwing, or better yet, get some help!

2.   Drive to Florida…
Or embark on any long trip the week after back surgery or a recent back injury.  Many of my patients travel a distance to have their surgery with me, and they have to get home that next week. 

The trip is safe and works out fine if

1. someone else is driving/flying them home,
2. they get up or out and walk around a bit every two hours along the way, and
3. they plan to rest a lot once they get home. 

I've had a patient surreptitiously plan his post-op trip so he drove the family the whole way from Cleveland to South Beach 3 days after surgery!  Then called to say he was really sore, his wound was red and swollen, and he had drainage on his unchanged bandage. Obviously there's nothing your local doctor can do for you at that point except shake his/her head!

If you have to travel to get home after surgery, have a plan for someone to drive you or to accompany you on your flight.  You can't be handling the luggage or running for a taxi.  Even better, stay a few days in town and have a wound check before you make an extended trip by car or plane. 

And just don't decide you're still going to take that golf trip/cruise/motor home excursion just five days after your back or neck operation. Plan ahead and give it a little time!

3.  Try moving “that rock”…
This is the gardener’s favorite mistake. Sure….it looked like such a little rock… But that was before you started digging!!!

​Every gardener knows this, but - for some reason - lots of gardeners can't stop themselves even though they know better.  Every little rock is just the top of a much bigger rock!

​It's probably a good idea to stay out of the garden for a couple of weeks after surgery or injury in any event, but I've had a number of patients that "just couldn't".  So, if that describes you, you should at least follow a couple of rules.

If you are recovering from any kind of fusion surgery for the neck or back, you may sit in your garden and enjoy it.  And that's IT!

If you've had a discectomy or decompression surgery you still need to take it easy for 3 - 6 weeks before you start doing anything very vigorous.

And, if you've had previous surgery, or you've had a back or neck injury in the past, you need to use good, common sense:

• Avoid repetitive bending and lifting. 
• Kneel or sit and work for a little while then get up and walk around. 
• Work for about 30 minutes at a time, then rest and reassess.
• If your back or neck starts to tighten up stop for the day. 
• And feel free to pick up the occasional stick or pebble, but do not start digging up tarps, pipes, roots, or rocks!  Know when to quit.

4.   Walking the dog(s) before you’re ready…
​Yes, you love your dogs and they LOVE you!  They’re glad to have you home and can't wait to get out and go for their walk!!!  But it doesn't matter if they are big or small, they’re going to try to kill you!  

​The big ones will bolt and drag you across the yard, which is disastrous if you've just had anything like back, shoulder or knee surgery, and the little ones will wrap that leash around your feet and trip you, which is just as bad or worse. 

​If you are recovering from a back or neck injury or from any kind of back, neck, or Orthopaedic surgery, be careful!  Share the dog-walking chore with someone who can help you, or have someone else give them a walk ‘til you're good on your feet.  

5.   Hosting that big Holiday, Thanksgiving, or any kind of affair involving lots of food, decorations, and furniture arranging too soon after surgery! Like the driving to Florida thing, you need to give yourself a little time to recuperate!  If you do have surgery around the time of a big important event, make sure everyone knows you are now the spectator, not the chef d'cuisine.  

Whether it's a family get-together, a wedding, or some other once in a life-time event, you will be much happier and the family will be much happier if you watch - or, at most, point to stuff for younger hands to carry - than if you aggravate your back or neck and end up miserable or worse.

Remember, that turkey weighed between 20 - 30 lbs before it was stuffed, and those big crocks, pans, and kettles - they're heavy when they're full.  If you're the only one that knows the recipe, that's fine, but you need to recruit good helpers any time you're trying to protect your back at the holidays.

6.   Anything involving a horse, a motorcycle, or an ATV -
Let's just say any non-standard form of transportation that you have to feed, hold upright, or try not to bounce out of or off of! 

If you've had a recent back or neck injury or you are less than 6 weeks out from surgery, this is a good time to groom the horse, rebuild the bike, or polish the ATV.  And any attempt to cut corners and get back to riding before you are ready will result in back and neck pain and spasm, at the least. 

Getting back to riding and back on the trail will be most successful if you take it in stages, build your strength up first, and then go back to activity a bit at a time. And when it comes to horses you can love them, comb them, watch them.  But no riding and no chores that’re measured in buckets, bales, or bags! 

I used to tell my post-op patients who were ready for normal, unrestricted activity that they could go back to "everything but rugby and rodeo!" and everyone would chuckle.  Until one day when the young woman I was so happy with started to tear up and sniffle. 

I had just one question - "You're a Barrel racer aren't you?".  "Yes sir" she replied tearfully.  So we had a nice long talk about sports rehab, and conditioning, and muscle strengthening to get ready to go back to her sport.

And I learned never to tease my patients who have horses!

7.   Deciding a tall stack of books will make an excellent step-ladder.  I've had a patient decide this was a sound strategy.  And at the age of 80 you'd think anyone would know better.  Any time you have any kind of idea like this, go sit down for a while until the impulse passes.  Please!!

8.    General Gardening. 
Of course – no bending, lifting, or twisting for 8 weeks after surgery! “But it’s spring and those roses won’t plant themselves!”  Again, find a helper, pay the gardener a little more, or enjoy last year's garden for a second season. 

If you are going to be "the muscle" in your yard then remember - nothing for 3-6 weeks after surgery, no lifting over 20 lbs until 6 weeks after surgery AND permission from your surgeon, and work in short stints - 30 minutes at a time, with a little walk about and rest to make sure your back or neck isn't tightening up.

And, please, if you do over-do it - ice, anti-inflammatories and rest are the only thing for it.  You won't need to call your doctor just to say you chopped wood all weekend and now your back is sore!  He/she won't be able to do anything but offer sympathy...

9.   Anything involving a chainsaw, engine hoist, or a bungee cord.  
Does anyone actually need say this…?  As with Holiday dinners, the person recovering from a recent back or neck injury, or recent back or neck surgery can watch heavy operations.  You can even point to stuff for younger folks to do.  You can display your wisdom and experience for all to marvel at.  

But don't try to pick up, twist, or torque anything that would make someone else grunt!
​
10.   Losing your pain medications –
Whether it's down the sink, down the toilet, off the front seat of the car – it doesn’t matter.  Now-a-days you can’t just call in for a refill. 

Your pharmacist likely won’t refill it no matter what your doctor says, because - by law - they have to keep track of how many prescriptions you fill in how many days.  And recently, it hasn't mattered if this is your first pain prescription in decades or one of a number you've gotten over the years, your pharmacist can simply refuse to refill your refill.  So take care of those pain  medications the way you really ought to - very carefully.…

As always…I want my patients to be active, and get back to full fitness and recreation when they've healed up.  But that always means taking care of your back and using good common sense at home and at work!
 
I hope you find this discussion interesting and useful.  If you have other questions that I can answer for you, please leave a comment below.  And feel free to like and follow my Facebook page to find more content that you and others might find helpful!

Cervical disc replacement - or disc arthroplasty - represents a powerful, well-established tool for treating herniated discs and degenerative disc disease in patients who have persistent pain and impaired function due to neck and arm pain, and who want to avoid a spine fusion if they can.

So, what’s the role of Disc Replacement Surgery in 2023?  There’s more good news and no bad news…
 
Good news!! Most patients with neck pain can recover without surgery:  80-90% will get better, and get back to normal activity with physical therapy, anti-inflammatory meds, rest, activity modifications, chiropractic manipulation…or, in some cases with nothing but time and TLC!
 
For the 10-15% of patients with a serious neck problem that just doesn't respond to time and supportive therapy, many will need an operation.  Many of these patients will need a discectomy - a removal of the cervical disc through the front of the neck - to relieve the neck pain and spasm, and the persistent arm pain, numbness, and weakness caused when a spinal nerve root is compressed by a degenerated or herniated cervical disc.
​

This is not a minor surgery, and rarely the first choice in a patient's care, but when pain is bad enough that it interferes with daily function, employment, fitness, and/or sleep…surgery starts to make sense.
 
Who needs spine surgery?
​
​We consider surgery the first choice for patients who have more serious issues such as fracture, infection, or tumor.  

​These conditions are relatively rare, often emergencies, and not the sort of thing we usually see in patients with persistent and long-standing neck pain problems.  
 
More commonly we are considering surgery for patients with wear and tear and degenerative neck pain problems, or those with a disc herniation related to repetitive trauma or a sudden accident.  

While we think of surgery as the ultimate treatment for neck pain that won't respond to anything else, we know that surgery is the most reliable solution for most causes of arm pain or weakness (radiculopathy) including disc herniation, cervical stenosis, or spinal instability.
 
Not every type of operation works for every type of spine problems, though, and while disc replacement surgery is an excellent treatment for disc herniations and disc degeneration, it is not a treatment for spinal instability or deformity, and not at all useful for treating tumors, infections, or fractures and dislocations of the cervical spine.  Cervical fusion remains the very best solution for each of those problems.
 
For those patients who do suffer neck and arm pain due to disc degeneration or herniation, though, disc replacement – or cervical arthroplasty – is an important option.
 
What is disc replacement surgery?

​Disc replacement surgery and disc arthroplasty surgery are the same thing.

​Also referred to as an “artificial disc” the implants used in these surgeries are designed to preserve motion in the spine after a discectomy (removal of the disc) and they have been shown to maintain motion and reduce the likelihood of degeneration at adjacent levels of the spine, something that often occurs in the years following a fusion. They are recommended for patients aged 18 – 70 years, but I, and other surgeons, have had excellent success in selected patients over the age of seventy years.
 
Artificial discs are placed in the neck through the front of the spine (an anterior approach) after a damaged disc has been surgically removed to treat neck pain associated with radicular pain – the arm pain caused by a “pinched” nerve.

​In the neck, this is exactly the same approach we use for most disc surgeries and all anterior cervical fusions.
 
Disc arthroplasty implants are not experimental or untested.  The implants we have now have been in development for over 40 years and similar designs have been available for patient care for nearly 2 decades.  There are disc replacement implants specifically designed for the cervical spine (neck) and for the lumbar spine (lower back).  

​They are specifically intended for treatment of degenerated or herniated discs in otherwise healthy patients.  There are no discs designed for the thoracic spine, and they are not intended to treat fractures, infections, scoliosis, or spondylolisthesis.

​And, to answer a pretty common question - you can’t undo an old fusion and put in an artificial disc later!
 
Artificial disc replacement can be carried out as an outpatient surgery, and utilizes many minimally invasive techniques, but it is not “minor surgery”.  When it comes to the spine, there is no such thing!  The importance of surgeon experience and skill is reflected in the careful diagnosis and plan for treatment, and the skillful approach and placement of the implant.

Surgeon experience with disc replacement procedures is important to the outcome here.  Ask your doctor what their experience level is and whether they've treated cases like yours before.
 
Disc replacements last a long time. How long? We don’t really know, because – unlike artificial hips and knees – we haven’t seen any of the ones we use today wear out.  We have had the opportunity to observe patients from Europe who have had disc implants in place for up to 35 years without failures. 

​As an investigator for early trials of two-level disc replacements, I have followed my own patients for more than 18 years without seeing any cases where the disc has worn out or deteriorated.
 
Who needs disc surgery?
Disc degeneration is a process that occurs over time, with wear and tear, age, and physical and environmental stress that causes changes in disc that separates each of the vertebral bodies in our spinal column.

Each disc acts as a shock absorber and a slightly flexible joint that allows the spine to move, but only so much.  As we age, the molecular components of the disc change, resulting in a loss of water content.  The disc loses height, becomes tougher and harder, and becomes a less successful shock-absorber. 

​As this happens, the disc may bulge or protrude into the canal where it can press on the spinal cord or nerve roots, causing arm pain, and it can lose its ability to control neck motion or cushion the small joints during motion, resulting in neck pain

​As these changes progress we see:

Axial neck pain – pain in the joints, muscles, and ligaments of the neck, causing focal pain and stiffness;

Referred pain - symptoms over the shoulder girdle muscles that support the neck - the trapezius, rhomboids, and paraspinous muscles
​
and Radicular pain - pain running down the arm and into the hand and fingers in a pattern or distribution typical of a specific nerve level, caused by pressure on the spinal nerve at that level.
 
Radicular arm pain can be uniquely intense and is the symptom that drives most patients to ask for surgery.

When these symptoms fail to improve after a trial of non-operative care, that’s when we consider surgery.
 
We generally consider surgery for patients with:

• Arm pain that has not responded to a good trial (6 weeks) of non-operative therapy
• Any progressive neurological deficit - increasing numbness or weakness
• A persistent neurological deficit with persistent radicular pain
• A surgically correctable lesion documented on imaging studies - MRI confirms a problem that can be corrected; or
• Any progressive instability or deformity, though these patients will more often require fusion than disc replacement.

 
​The traditional treatment for cervical disc herniation has been fusion, typically described as an "anterior cervical discectomy and fusion" (ACDF).  

​That’s a surgery through the front of the neck, with complete removal of the disc back to the spinal canal and removal of disc or bone spurs that may be pressing on the nerves. 
 
But, why fuse the spine after we get the disc out?
 
The interbody fusion is performed by placing a cage or bone spacer between the endplates of the adjacent vertebrae to restore the intervertebral and foraminal height, immobilize the painful segment, and provide permanent stability.

Fusion does all of these things reliably and well!
 
But fusion eliminates motion at the treated level and increases stresses in the adjacent levels above or below, and that can lead to breakdown at that adjacent level, (adjacent level degeneration) sometimes just a year or two after the initial surgery.

​What does the Artificial Disc do that’s different?
 
The cervical disc arthroplasty or disc replacement is intended for the patient who:
-   needs the discectomy and would otherwise need a fusion, but
-  still has motion at the injured level and wants to avoid the down-time required for a cervical fusion to heal,
-  wants to avoid the risk of non-union (fusion failure) that might require another surgery, and
-  wants to avoid the risk of adjacent level disease down the road.
 
The approach for the disc arthroplasty, and the removal of the damaged or herniated disc during disc replacement surgery is exactly the same as in the ACDF, but instead of placing the bone or a fusion cage in the empty disc space, disc replacement surgery fills the space with an artificial device that restores disc height and alignment and preserves the motion of the original disc.  

​This allows the treated spinal level to move more naturally, reducing the risk of adjacent level degeneration down the road.  And there is no need for prolonged immobilization or restricted activity, as we don't need to "wait for fusion".

Who is the best candidate for a disc replacement surgery?

• Patients with at least 6-12 weeks of pain that hasn’t responded to a good trial of conservative therapy
• Patients with radicular arm pain or weakness causing serious functional impairment
• Patients whose surgical problem is limited to one or two disc-levels
• Patients with disc disease at one or two-levels between the C2-3 to C6-7 levels
• Patients with good bone quality and fitness
• Patients who demonstrate adequate residual motion at the treatment levels on flexion and extension x-rays.

 
 
Where will disc arthroplasty work well?
 
Success has been unequivocally demonstrated in the well-maintained but painful disc, in the young and active patients.

​There are over 150 peer-reviewed publications analyzing investigational FDA trials, long-term follow-up studies, and large multicenter studies to ensure the safety and effectiveness of these implants.  These studies have shown that, when used for the correct indications in the properly selected patients, disc arthroplasty provides significant advantages over traditional fusion procedures.  They are not "experimental or investigational", and their effectiveness is proven.
 
Do they work in everyone?
As we noted at the top of the page, these implants are not intended to treat problems like infections, tumors, or fractures, and they can't undo what has already been done.
 
But they can be considered in almost every patient who would be a candidate for a one or two-level ACDF, so long as the patient has good bone quality and still has motion left at the level to be treated

​Severe osteoporosis makes any sort of stabilization difficult, and disc replacement is as likely to fail as a simple fusion, but would require a more complex revision that a failing fusion might.  And, a patient with no remaining motion at an arthritic level has already started to fuse naturally, and is unlikely to get good motion back  with any operation.  The disc arthroplasty is a motion-preserving procedure, but it can't undo a solid fusion.
 
What about age?

​If patients are reasonably fit and bone quality is good, age isn’t a big problem!  Large studies and FDA trials of disc replacement have included patients up to age 69, and my experience with patients older than this suggests disc replacements are actually better tolerated than the traditional fusion.

At age eighty, some of my fit patients do very well with outpatient disc replacement surgery, returning home within a few hours of their operation, with a soft collar, and no restrictions of daily activity.  There has to be good bone quality and good residual disc motion, however.

What about activity level?  

​Patients who are athletic or hard working can depend on disc replacements to hold up to their physical demands – the discs are not fragile and the patients don't need to feel fragile either.  Patients don't have to restrict their fitness or work activities beyond what makes sense for normal people.
 
What about smokers?

Well , first off – stop ! It’s not good for you.  However, smoking does not affect the fixation of the disc replacement implant the way it can impede bone formation needed for fusion.  Studies to date have not shown smokers to have any poorer outcome after disc replacement surgery than nonsmokers.  That's just not the case with fusion, so disc replacement is probably a better choice for you too.

​With all that in mind, cervical disc arthroplasty continues to offer an attractive and valuable option for most patients otherwise indicated for cervical fusion to treat their neck and arm pain. 

​If you’ve been offered a fusion surgery, ask your surgeon if you’re a candidate for disc replacement!
 

​As always, I hope you find this discussion interesting and useful.  If you have other questions that I can answer for you, please comment below.  If you want more updates on blog posts please like and follow me on my Facebook page.
 
And feel free to like and share this content with others that might find it beneficial!
 
Thanks for reading.

​who have now developed new neck pain or a new disc herniation at the level above or level below their fusion.  

​This is called Adjacent Segment or Adjacent Level Degeneration, and it is a well known and common complication of cervical fusion surgery.  And, until recently, it has almost always been treated with another fusion.

​That treatment strategy was the only one available up until ten or fifteen years ago, and it would, as you might guess, tended to start a vicious cycle of fusion and adjacent level herniation that often lead to multiple surgeries and multilevel fusions in many other wise fit and active patients.  Even today there are many spine surgeons who will advise their patients in this situation that there is nothing for it, they're going to need another fusion.

I've treated enough patients over the years to know that an active, young patient with a 4-level fusion is not often happy with their result.  Neck pain is constant, stiffness and limitations in motion are inevitable, and there is always the likelihood that any level that's still mobile is going to degenerate, become painful and require another round of surgery.  Again, up until ten or fifteen years ago there really wasn't much else that could be done.
​ 
That vicious cycle was one reason surgeons and non-surgeons alike would advise their patients to avoid surgery until they just couldn't take it anymore.

​That approach to neck pain and disc disease is changing, largely due to the advent of disc replacement surgery as an alternative to fusion.

​Disc replacement surgery is  growing in popularity, both because of the interest of patients, but also because of the growing number of surgeons who have been trained in these surgical techniques and who have become familiar with the vast experience of other surgeons who have preformed large clinical trials and extensive peer-reviewed studies to document the advantages and safety of the devices we now have available to us.

​However, there is still a lot of misinformation out there, and it’s sometimes hard to figure out what facts are important to your individual condition!  And that's particularly true when it comes to patients who have an adjacent level disc herniation or degeneration adjacent to a previous fusion.
Here are five points that are particularly important for these patients and their care-givers to know:

1. Disc replacement surgery (also called disc arthroplasty) has been available for roughly two decades now, and has an extensive background of supportive research and surgical experience.  Use of an “artificial disc” to preserve motion in the spine after a discectomy (removal of the disc) has been shown to maintain motion and reduce the likelihood of degeneration at adjacent levels of the spine, which often occurs in the years following a fusion surgery.  

​Disc replacements have been widely studied in a number of controlled, FDA approved trials, and have proven safety and effectiveness in all of those studies.  For those studies, the patients included were very specifically selected, however. Disc replacements were recommended for patients aged 18 – 70 years, typically, but were not allowed for any older patients, patients with other illnesses, and - importantly - patient who had had a previous cervical fusion.  

​It wasn't that they were not expected to work for those patients.  Instead, it was known that including patients with too many variables in their background would make the analysis of all of data much more difficult, and could confuse the study.  Comparing patients who had had a previous neck surgery to patients who had had no previous surgery would have made these early studies impossibly complicated and could have made it impossible to reasonably document their safety and efficacy for any patient. 

​2. Artificial discs are placed in the neck using exactly the same surgical technique used for anterior discectomy and fusion surgery, the commonly recommended treatment for adjacent level disease.  The surgical approach is through the front of the neck (an anterior approach), and the damaged disc above or below the previous fusion is surgically removed to treat neck pain and the associated radicular pain – the arm pain caused by a “pinched” nerve - in exactly the same way whether a fusion is planned or a disc replacement performed.

​In the neck, this is the same approach we use for most disc surgeries, but it has to be carried out with added care when a previous surgery has created scarring in the vicinity.  That said, there is no greater difficulty with this approach when an arthroplasty is planned than for fusion.  In fact, revision surgery for fusion often requires removal of the old plate and screws before the next level can be fused, while this is not usually necessary for an arthroplasty operation.

​3. Disc arthroplasty implants have been in development for over 40 years and have been available for patient care for nearly 2 decades.  The implants now most widely used have been developed for placement with the most simple techniques and don't require complex surgical techniques such as placing fixation screws or fins, or cutting slots into the bone.  

​In fact, disc replacement is generally focused on the goal of minimal bone removal and minimal soft tissue exposure, which often allows a disc to be placed successfully without ever exposing the fused level above or below.

​These are implants specifically designed for the cervical spine (neck) and they have very specific applications – treatment of degenerated or herniated discs in otherwise healthy patients.  There are no discs designed for the thoracic spine, and they are not intended to treat fractures, infections, scoliosis, or spondylolisthesis.  And you can’t undo an old fusion and put in an artificial disc later!  But these discs treat the adjacent level cervical discs just as well as they do the primary disc herniations included in those original studies.
 
4. Artificial disc replacement can be carried out as an outpatient surgery, and utilizes many minimally invasive techniques.  So, even in cases where previous surgery has created a scar or affected other levels, disc arthroplasty can still be carried out without the extensive surgery needed to remove and replace a fusion plate with a longer plate, for instance, or move the delicate tissues away from the old fusion bed to get previous hardware out of the way!  

​The importance of surgeon experience and skill is reflected in the ability to recognize the ability to preserve motion at the adjacent level and carry out the motion preserving surgery with the minimum of soft tissue dissection and injury.  Your surgeon will provide a careful diagnosis and plan for treatment, and provide the skillful approach and placement of the arthroplasty implant that allows a rapid recovery from surgery and rapid return to function. 

​Surgeon experience with disc replacement procedures is important to the outcome in these revision operations.  And, it's ok to ask your surgeon what his or her own experience has been like.
 
5. Disc replacements last a long time and protect those adjacent levels for a long time as well. With most contemporary arthroplasty implants we use we don’t really know how long they will last, because – unlike artificial hips and knees – we haven’t seen any of the ones we use today wear out.  Most patients know either from their own experience or from what they've seen grandparents or family members go through, that hip and knee replacements tend to wear out after 10 - 15 years, and often need to be revised. 

​With disc replacements, we have had the opportunity to observe patients in Europe who have had disc implants in place for 35 years, and we still have not seen any failures.  Some of the early designs did not do as well, but those aren't in use any more and have not been for years.  

​In my own experience I have not seen disc replacement fail or require revision.  And I have followed my own patients for more than 18 years without seeing any cases where the disc I implanted has worn out or deteriorated.

Is this opinion or is this fact?  It is important to know that there have been over 150 peer-reviewed publications documenting the results of long-term trials and studies of total disc replacements, both here in the US and abroad.  Including investigational FDA trials, long-term follow-up studies, and large multicenter studies to ensure the safety and effectiveness of these implants, almost all of these papers speak to results for primary patients and not those treated for adjacent level disc disease. 

​These studies have shown that, when used for the correct indications in the right patients, disc arthroplasty can provide significant advantages over traditional fusion procedures.  Cervical Disc arthroplasty is not experimental or investigational, and the effectiveness of disc replacement is proven.
 
So, is there evidence that the same results can be expected for patients needing treatment for adjacent level degeneration?  Is there good evidence that disc replacement can be carried out in a revision surgery as safely and effectively as it can for a primary procedure, or - more to the point - as safely and effectively as for a patient receiving fusion for that revision procedure?

​There is that evidence, as well as numerous series and smaller reports establishing the suitability of motion preservation for these patients who've already lost a considerable amount of their normal motion due to their first fusion.
​
As an academic surgeon, one of my responsibilities over the years has been to track and document the results of my own patients, to identify problems before others encounter them and to establish the benefits and success of other techniques that other surgeons might subsequently take advantage of.  This has also included biomechanical and anatomical studies of surgical technique and implant design, but follow-up of individual patients has always been crucial to good surgical care and the improvement of every kind of treatment.

​In my most recent analysis of outcomes in patients treated both for primary disc disease and those with disc herniation or degeneration following an older fusion, we were able establish strong support for the clinical opinions discussed above:  Comparing adult patients receiving one or two level cervical disc replacements for radiculopathy and/or axial neck pain who had no previous surgery to patients treated the same way, who had adjacent level spondylosis or cervical fusion, and comparing all of them to a series of similar patients treated with fusion for similar degrees of neck pain and radiculopathy we found that:
​
Patients undergoing a primary cervical disc replacement reported excellent satisfaction and pain relief 2 years down the road - 76% percent reported minimal neck pain even with activity, and 36% reported no neck pain at all.  86% reported little or no arm pain at that point, of which 59% reported no arm pain symptoms at all.  Compared to this, the patients who had disc replacement for adjacent level degeneration did as well or better - 88% percent reported minimal neck pain with activity, of whom 50% reported no neck pain at all,  and 100% reported little or no arm pain at 2 years, of which 75% reported no arm pain symptoms at all! 

Compared to patients having cervical fusion - well, they did well also, but as early as 3-4 years after surgery 18% were reporting moderate to severe neck pain, and a few were experiencing moderate arm pain.  I was pleased to present the preliminary report of this peer-reviewed material at the MidAmerican and the Western Orthopaedic Association Annual Meetings in 2022.

While these numbers are too small to prove anything, they certainly support the use of a disc replacement device in patients who've already lost some neck motion, as opposed to forcing them to undergo additional fusions.
 
And what about the safety?

In our analysis of these patients - none of the patients in any group suffered a complication either during or after surgery, and none of the patients treated for adjacent level degeneration has required any other surgery.  Any neck operation requires superior care and technique to get a good result without complications.  None of these procedures should be considered minor surgery, even when they can be performed as outpatient operations. 

So, if you’ve been told you need to have a neck fusion, for a primary disc herniation or disc degeneration or for a problem that has arisen following a previous fusion, it’s ok to ask “is there another way - a better way - to treat this?”.  It's worth getting a second opinion to see if disc arthroplasty might be that better way for you!
 
I hope you found this informative and interesting! You can learn more about disc replacement surgery, and other types of spine surgery and treatment, by checking out more sections of this website, and you can follow me on Linkedin or Facebook to learn about new updates and post that may help you take care of your back and neck. 

​Thanks for reading!
​

​Low back pain is a common - essentially universal - problem for modern men and women.  Even though we continually improve our tools, our work environments, our recreation, we still encounter back and neck pain problems that interfere with or even curtail our normal daily activities.
 
So back pain problems must have been even worse for our ancestors, right?

It's not so clear-cut.  Although they are widespread among modern man, arthritis and back problems were not a common affliction among our ancient ancestors, at least not to the extent they would talk about them much.
 
While we do have extensive medical treatises and descriptions of illness and injury dating back to the hieroglyphics and Egyptian times, there is very little written about arthritis in early literature: Egyptian papyrus manuscripts (the Edwin Smith papyrus) discussed a wide variety of illnesses and injuries, but did not address the problems of joint disease at all. 

Disorders of infection, and skin lesions, and deformity were discussed, but the only discussion of spinal disease alluded to the care of someone who falls from height and injures his back, and can no longer move his legs or control his bladder; that patient cannot be helped and will, the manuscript tells us, soon die.  

And that was pretty much the standard of diagnosis and treatment up until the later decades of the 1800's.  Low back pain?  When you devoted your life to hard labor and warfare it had to be an issue, but, I guess, when you're building pyramids for a living you don't mention it.

It is difficult to find, among all the human archeological or fossil evidence, many specimens with typical knee or hip degenerative joint disease of even a moderate degree.  Why is it that a disease process so prevalent today would be so hard to find in material just a few hundred years old - a blink of an eye in evolutionary time? 
 
Is osteoarthritis, as we know it today, kind of a new disease to man? Is it truly a byproduct of civilization, reflecting changes in diet or environment, or alterations in activity patterns? 
 
The fossil remains of our predecessors suggest an interesting answer to these questions, and may provide insight into the evolution of bone and joint disease in modern mankind.
 

​Paleopathology is the scientific study of disease processes - pathology - of the past, defined as "the science of the diseases which can be demonstrated in the human and animal remains of ancient times". 
 
The importance of paleopathology lies in the ability to carefully examine the physical remnants of ancestors or ancestral species, and to determine not only how these animals or individuals functioned normally, but also the diseases which they faced and the way they responded and adapted to them.
 
The Ancient Fossil Record is all about bones:
Evidence of disease has been found in the fossil remains of dinosaurs and early mammals predating the appearance of man by 100's of millions of years.  

​Since bone is the only tissue remaining in most of these specimens, very little can be said about diseases of the blood or visceral organs unless that disease also had an effect on the bone.  For instance, we do know that bacteria and parasitic organisms were around and probably caused infections in pre-historic times much as they do now, but the only evidence we have of those infectious diseases comes from the rare examples where bone was involved.
 
Mummies, on the other hand: 
Mummification - either accidental or intentional - does provide an opportunity to study soft tissue disorders, infections by bacteria and parasites, and toxicology in ancient man

Although we are most familiar with mummification as it was practiced in ancient Egypt, mummification can occur naturally in any perpetually arid or frozen environment.  Well preserved mummies have been found in the Peruvian Andes, the Arctic, Siberia, and in the drier climates of the Mediterranean, North Africa, Australia and Japan.  Chemical preservation has produced mummies in pre-Columbian salt and copper mines of South America, and has resulted in a series of remarkable "Bog bodies" in Northern European peat bogs. 
 
The Tollund man is one of several bodies recovered from the peat bogs of northern Europe that demonstrated such startling preservation of the body's soft tissues - including features such as eye color and finger print pattern - that local police were summoned to the discovery, even more than 2,000 years after death.

​The maintenance of the soft tissues in Egyptian mummies is often remarkable. The diffuse rash seen on the face, torso and thighs of Pharaoh Ramses V, and on other mummies of the period, is highly suggestive for smallpox.  Histological examination confirmed the diagnosis.  The quality of histologic material after mummification can permit sophisticated analysis, and DNA analysis now opens the door to far more sophisticated study and pathological diagnosis.  

​Implications:
The fossil record of disease has historical and clinical importance, providing information about the types of diseases present prior to careful written accounting, and the spread of disease among peoples and populations who may not have had the capacity or time to write. 
 
For example: scholars argued for years that the hookworm, an intestinal parasite, was introduced into American native populations by infected African slaves brought to South America by the Spanish.  For years there was no physical or descriptive evidence to suggest that hookworm had ever existed in the New World prior to the arrival of the Europeans.  In 1960, however, while studying intestinal specimens from a 500 year old, pre-Columbian mummy found in Peru, researchers found well preserved examples of the parasites still attached to the intestinal wall.  

​Scanning Electron Microscopy showed details of the worms' head and buccal cavity, allowing conclusive identification of both the species and variety, proving that this parasite was established in America long before the arrival of the Spanish.
 
Musculoskeletal Paleopathology: 
What, then, were the predominant forms of musculoskeletal disease among our ancient ancestors? 
 
Deformity was a common cause of dysfunction in ancient man.  

​The deformed foot of the Egyptian Pharaoh Siptah, once described as an example of club foot, appears to modern observers to more closely mirror the residual deformity caused by polio. X-rays of Siptah's foot show a specific deformity classic for paralysis and not clubfoot, and the limb is shortened, a combination commonly seen with polio. 
 
On the other hand, examples of true, untreated clubfoot have been found in both Egypt and Europe, were illustrated in Egyptian writing, and seen in archeological specimens.  One European specimen from the Bronze Age demonstrates the dramatic inward rotational deformity of the mid-foot, (adduction), and rolling-in of the heel (inversion) so severe that the foot was actually inverted - upside down -  to the point that this Bronze age man could only walk on what should have been the top of his foot.

But walk he did, evidenced by the extensive calluses and bone spurs that formed on the dorsal surface of those bones.
 
Systemic disorders or infections that left their mark on bone are also apparent among the fossilized and preserved remains of early man.  Examples of leprosy have been found in ancient Egyptian material and throughout Europe.  Specimens exhibiting signs of syphilitic infection are quite common in Native American remains of both North and South America, but have never been found in Egyptian material. 

​Tuberculosis, common around the globe today, was common then too. And since it did attack the bones - and the spine - quite frequently, we see it clearly in the archaeological record.

​What of the other common diseases of bones and joints we treat today, particularly those leading to degenerative joint disease and degenerative disc disease?
 
First of all, disease processes linked in any way to aging are significantly more common in our modern population than they would be in any period in the past.  We should expect significant differences in the incidence of most common cancers, chronic disease, and osteoarthritis relative to today's populations.  To be blunt, people didn't used to live that long!
 
The average age at death in Bronze and Iron Age man was approximately 25-35 years, depending on where you looked.  In some ancient cemeteries as many as 50% of all bodies are of infants and small children, which brings the averages way down, but even among those that made it to adulthood, longevity was not promised.

​Prior to the 1700's, people just did not live very long.  Going back 3,000-4,000 years, even among the Pharaohs -who were the best fed, most carefully protected individuals in the relatively advanced land of Egypt - the chances of long life were slim.  Of 26 royal mummies studied at the British Museum, only 10 had lived to the age of forty, and only 2 had lived beyond fifty. 
 
King Thutmose I, acclaimed as a great military leader, greatly expanded the territories and influence of Egypt through victories over both the Nubian and Syrian nations.  He sired three princes and a princess during his reign as Pharaoh and established a successful dynasty. 

​Yet x-rays of the Pharaoh's mummy revealed open growth-plates in the proximal humerus, distal femur, and proximal tibias, and no degenerative joint changes in any joint.  The fossil record shows us that, despite all of his accomplishments, Thutmose I was dead before he reached the age of 21 years!.

This dramatic improvement in individual survival has had an effect on the types of diseases we see in mankind.  In comparing a modern population - with an expected survival into the 70's and 80's - to an ancient population where only 5% of the people survived past age 40 - three predictions might be made:

• First, we can predict that diseases that don't start until adulthood but then progress throughout life will appear more common and far more severe in modern populations.  These conditions will be present among ancient peoples, but less frequently and only in their mildest forms.  Think arthritis.

• Second, we can predict that some diseases that typically occur as a result of some repetitive insult or toxic exposure will be rare in ancient populations, and others very common.  Diseases that require a threshold of exposures or trauma, such as carcinogen exposure, may not reach that threshold in the ancient population, but will become increasingly common in modern populations depending on age.  On the other hand, unprotected exposure to things we now avoid might lead to more common disease findings.  We see this in mummies around the world where dust and sand inhalation has resulted is a frequent finding of silicosis, a disease of the lungs we still see, but less frequently, today.

​

• Finally, we can predict that diseases that typically occur only with advanced age will be rare or unseen in ancient populations despite being common or ubiquitous in modern elderly populations, showing a significant difference in incidence when the two groups are compared, unless matched for age. Think of our most common cancers and osteoporosis.

 ​As an example of the first principle, consider osteoarthritis.  We know that degenerative joint disease is rarely present in people before 30 years of age, unless associated with a traumatic injury of the joint, and that clinically significant knee or hip degeneration rarely occurs before the age of 40.  This means that, even though the degenerative process was ongoing, only 5% Bronze or Iron age men would be likely to develop clinical osteoarthritis prior to their death, unless associated with some other pathology.
 
Causes of early, advanced degenerative joint disease in pre-historic men would be similar to the what we see among young patients today, occurring as a result of aseptic necrosis, or pediatric disorders like Perthes disease, slipped capital femoral epiphysis, and congenital dislocation or dysplasia of the hip.  

​These entities affected young individuals then as now, and produced crippling joint disease among the generations that came before corrective orthopaedics.  In fact, many archeological specimens presented in scientific texts as examples of "osteoarthritis" do show deformities more suggestive of acetabular dysplasia or slipped capital femoral epiphysis than of typical osteoarthritis.
 
End stage degenerative disc disease, the type we see after 15 - 20 years of symptoms, is very rare in Bronze Age populations.  What is seen is a high incidence of mild to moderate vertebral spurring, suggesting that the same degenerative processes were ongoing, but never got too severe.  Primitive man rarely lived long enough to "wear out" his vertebrae, though the rigors of his lifestyle frequently left a mark on his spine.
 
The leading cause of joint destruction in prehistoric populations was trauma.  This represents the second prediction above:
 
Anyone who accumulates sufficient exposures (trauma) can develop the disease, but if you don't live very long you need to experience a large dose early on to manifest the clinical disease.  Meaning, prehistoric man would develop joint disease after major traumatic events, but rarely "got enough steps in" to generate serious osteoarthritic degeneration.

To make matters even tougher, prehistoric man had to survive his fractures, and avoid starvation, in order to live long enough to develop even acute post-traumatic arthrosis.  There are examples of prehistoric poly-trauma, but they aren't common, and degenerative joint disease is seen in the survivors of these injuries.
 
One very old example of an individual surviving multiple injuries long enough to develop secondary degeneration is of a Neanderthal skeleton from an Iranian cave site discovered in the 1950's.  "Shanidar 1" was apparently a rare survivor of major trauma.  

​Standing about 5'6" tall, Shanidar 1 lived approx. 50,000 years ago, and probably lived to an age of 40 years.  Years before he died, Shanidar 1 sustained at least one, and more likely a series of serious musculoskeletal injuries.  At one point, probably a decade before he died, he sustained a severe crushing injury to his right arm and leg.

​Fossil remains show that he suffered an amputation of the right arm through the distal humerus, fractures of the clavicle, scapula, and right knee, and a crush injury to the foot.  He also sustained, perhaps at a different time, a crushing blow to the left side of his head which may have blinded him in the left eye. 

​Any time prior to the advent of antibiotics and modern medical care this combination of these injuries could have proved fatal.
​
Nonetheless, Shanidar 1's amputation healed, he survived the chronic osteomyelitis of the open clavicle fracture and severe post-traumatic degenerative joint disease of the knee and ankle.  The extent of bony healing and the degree of joint degeneration suggest that he lived for many years after his injury.

​Considering the violent and uncertain environment in which he lived it is impossible that he could have survived without extensive support from members of his tribe.
 
Septic arthritis was likely a cause of degenerative joint disease in prehistoric man, but acute sepsis in these people was probably routinely lethal.  Those dying soon after the onset of their osteomyelitis or septic arthritis would leave no bony evidence of their disease.  Chronic infection and obvious joint destruction would be more likely to occur in those suffering from tuberculous disease.  And we do know that was a thing!
 
There are many drawings and sculptures in both Old and New World antiquities illustrating the common features of tuberculosis.  There is excellent evidence that tuberculosis was prevalent in both hemispheres in pre-Columbian times. The mummy of an Egyptian high priest demonstrates the classic findings of tuberculosis of the thoracic spine recognized by physicians over the past centuries.

​A marked kyphosis and a large psoas abscess are clinically apparent in this mummy.  The severe kyphosis commonly caused by tuberculosis could produce paraplegia, a fatal condition in ancient times.
 
Finally, in considering diseases that only appear with advanced age, the age differences in modern and ancient populations greatly affect the perceived prevalence of some disorders.  Cancer would be an example of this third principle.  The tumors that commonly produce skeletal destruction in modern man most often arise in primary cancers of the organs, and only attack the skeletal structures if the patient survives long enough to develop metastases. 

​This would include most metastatic neoplasms, which make up 95% of all skeletal lesions we deal with today.  These tumors generally don't emerge until the fifth and sixth decade of life - or later - and probably had little impact upon prehistoric man and very little effect on his skeleton.  For this reason, we see a disproportionately large number of primary tumors - tumors of youth and young adulthood - predominating in archaeological material.

Ancient man didn't have a predisposition to these primary tumors compared to metastatic tumors, s/he just lived long enough to get the one type, but rarely long enough to get the other.
 
Post-menopausal osteoporosis would be another example of this third condition.  This malady is ubiquitous in our modern society with millions of elderly members, but would be exceptionally rare in a population where less than 5% of people survived their fifth decade.  For this reason osteoporosis is a disease entity that is not mentioned in texts on paleopathology, and the sequelae of osteoporosis - hip fractures, thoracic compression fractures - have not been reported.
 
It is apparent that many of the disorders which afflict man today have been present for thousands of years, little changed from the diseases represented in our earliest fossil material.  

​What has changed is this:

The prolonged life span of contemporary man has produced a previously unseen developmental phase in our life-cycle, within which new responses to chronic disease are necessary.  And, while we are getting better at treating problems in this new phase of life, we haven't been at it that long and we are still working out alot of kinks!
 
Conclusion:

​The primary cause of symptomatic joint and back degeneration throughout the early history of man was most likely trauma, less frequently sepsis, and rarely, primary osteoarthritis.  Congenital and acquired deformities, aseptic necrosis, and pediatric conditions such as congenital dysplasia, slipped capital femoral epiphysis, or Legg-Calve-Perthes disease may have played a relatively greater role in this much younger population, as they occur in a younger age group and are not lethal conditions.  Sepsis, though common, probably killed so many of its victims that degenerative disease due to chronic infectious arthritis would be uncommon. 

In most cases, then, degenerative joint disease in ancient man was the result of an acute injury, not a response to chronic wear and tear.  And it's also likely that few people of ancient times - Neanderthal through the middle ages - would survive long after an injury like that without considerable social support.  Even then, few people lived long enough or comfortably enough to call an arthritic hip or aching back their biggest problem and that likely explains why we read so little about those problems in our oldest literature or see them in the fossil record!

As always, I hope you find this presentation interesting and educational.  If you did, follow me on my Facebook page for updates on future posts and material on spine care and spinal surgery.  If you have suggestions for other questions that I can answer for you, please comment below. 

And feel free to like and share this content with others that might find it interesting or beneficial!
 

​A disc herniation can develop slowly over time or appear out of the blue, with no warning.  It can happen when you might expect it, while lifting too much or working at a heavy job, or when you'd least expect it - while sitting at your desk or turning to answer the phone.  Most will get better with non-operative therapy but, when they don't, surgery is often necessary.  The good news?  In the case of lumbar disc surgery, the operation is minimally invasive, very reliable, and quite effective!

What is a disc herniation?

​A disc herniation, or Herniated Nucleus Pulposus (HNP) is an injury to the disc that separates two adjacent (usually lumbar) vertebra and maintains spinal alignment and function.  The disc is a tough structure made up of an outer annulus, constructed of overlapping tough fibers (like those bias belts we used to see on tire commercials) and a more spongy and softer material in the center called the nucleus pulposus.  

The annulus keeps the nucleus contained so it can act as the shock absorber as the spine moves and works during the day.  When a disc herniates there is a displacement of the central portion of the intervertebral disc (nucleus) into or through the annulus fibrosis.

​A painful symptomatic HNP produces chemical and mechanical irritation of the adjacent spinal nerve, causing radicular pain - pain running down the length of that nerve into the leg or foot.

There are many different grades of disc herniation, but whether they cause symptoms depends not only on the size of the herniation, but the size of the spinal canal into which it protrudes.  Some small people have lots of extra room and may not be bothered much by even a large herniation.  Some very big people have a surprisingly tight spinal canal and may find even a modest herniation intolerable.

What kind of herniations are there?

You may see, if you read a radiologists report, discs described as Protruding or Herniated or Bulging and wonder which one is worse?  The first thing to know is that this terminology is descriptive, not really classified in any way, and can mean different things to different people.  And, different readers use different terms for the same thing. 

The term "Herniation" implies displacement of nucleus material, not just bulge of the annulus, but some radiologists and doctors will call any noticeable bulge a "small herniation".  Why make this point?  Because I often meet patients who've been assured that they "have four herniations" in their back, when only one is truly herniated and the rest are pretty much normal for anyone over 40! 

The Normal nucleus pulposus sits centrally in the disc, 2/3 back from anterior rim of the annulus. The normal annulus fibrosis contains the nucleus, and does have a slight convex bulge when it's healthy.  There is no impingement of the annulus on the adjacent neural structures - the nerve roots or the spinal cord/cauda equina.

​A disc Protrusion implies that the nucleus protrudes through inner annulus and pushes the outer annular rim out into canal or foramen, impinging on the nerve roots and causing pain.  A protrusion may be broad-based or focal.

​An Extrusion implies that the nuclear material has pushed through the outer annulus and herniated into canal where it can now directly press on the nerves or irritate them due to inflammation. An extrusion can be sub-ligamentous, contained within the last layer of the annular structure, or free, meaning completely out into the canal. And, direct contact of this nuclear material with nerve root is irritating.

​A less common presentation is a Sequestered Herniation.  In a sequestered disc, the nuclear fragment has pushed through into canal, become separated from annular defect and remaining extruded disc, and may migrate some distance away from its original position.  

​MRI's show us this well, but if the MRI is old, the migration could happen later and leave you with a disc fragment that isn't visible during surgical decompression.  There's a reason we want a "recent" MRI!

Why does a herniated disc cause so much pain in the leg and foot?

Direct pressure on the adjacent nerve root results in numbness and weakness in the radicular distribution of the nerve, the region that that particular nerve gets sensation from and sends muscle messages to.  Direct pressure can cause rapid loss of sensation, severe pain and weakness, but even light pressure can be a problem. 

​With time, inflammation starts up around the herniation and the compressed nerve, and with inflammation, even minor irritation of nerve generates intense pain in the radicular distribution.  And, if the herniation is in just the right (or just the wrong!) spot, pressure over a specific nerve center called the Dorsal Root Ganglion generates immediate and intense pain. 

Depending on which nerve is involved, a patient with a symptomatic disc herniation loses sensation over specific area that that nerve serves (dermatome), loses strength in the specific muscles that nerve innervates, and may lose reflexes in specific joints those muscles control.

The Classic presentation of an acute HNP, often follows this pattern:

• Sitting and flexion produce progressive back and buttock pain, sometimes for months
• Over time the back pain intensifies, and then something "Pops" and the back pain goes away…
• Next day, leg pain has replaced the back pain and the patient gains a whole new perspective on pain…

 
That new pain is Sciatica - radicular pain traveling down one of the nerves that make up the sciatic nerve - L4, L5, or S1 - which are the most commonly affect because most disc herniations occur at L4-5 and L5-S1 levels.

​Because the anatomy of the nervous system is very consistent, and we can ask the patient exactly where their leg pain is most intense, clinical diagnosis of disc herniation and the level is usually precise and reliably.  In those cases surgical treatment is also, usually, precise and reliable.

Will disc surgery make my back pain go away?

That's harder to predict.  While most patients do get improvement in their low back pain, the actual cause of anyone's back ache is usually uncertain due to the many potentially pain sensitive structures in lumbar spine.  So, if the disc herniation was THE cause of the back pain, the prognosis is good.  If muscular deconditioning, degenerated discs at other levels, or arthritis of the small facet joints was the primary reason your back hurt, discectomy may not solve everything.

Will disc surgery make my leg pain go away?

This is far more reliable.  If pain is caused by direct pressure on the nerve or even direct contact with the nerve, removing that disc fragment relieves the leg pain symptoms in the vast majority of cases, and sometimes immediately.  How reliable is this?  It depends on how reliable our diagnosis and surgical plan were:

In years before MRI or myelogram were available, surgery was based on just one thing - the doctor's clinical examination of your neurological system.  Based on just this, a discectomy was more of an exploration, but was still successful in about 55% of cases.

​Over time, doctors became more aware of what was causing the pain and developed better examination techniques, one of which was called the Straight Leg Test.  This test slightly stretches the nerve over the protruding disc, and intensifies the pain for a moment, confirming the diagnosis that there is a herniated disc to be treated.  With the neurological exam and the straight leg test, surgical success improved to over 85%.

We still do that physical exam and are still pretty sure what we need to do before we do anything else, but now MRI lets us look inside the spine anytime we need to to confirm our suspicions and characterize the size, shape, and location of the disc fragment. 

With the addition of a quality MRI study, surgical success is routinely better than 95%, meaning 19 out of 20 patients come back saying:

"I'm much better.  I'm glad I did it.  Wish I'd done it sooner!"

​Will I get that "great" clinical result?

Our best surgical results are obtained among patients with

• Predominantly leg pain
• Minimal back pain
• Clear-cut neurological signs
• An MRI imaging that correlates with exam
• And no “baggage” - no history of previous surgery, medical disorders such as diabetes or neuropathy, thyroid or metabolic disease, chronic steroid or pain medication use.

This doesn't mean surgery won't work for you if you don't fit one or more of these criteria, just that it's harder to predict your result.

​What are the chances it's something that's more difficult to fix?

There are a couple of spinal conditions that we always look for on spinal imaging during our work-up.  Fortunately, the principle imaging studies we always do for a disc herniation - x-ray and MRI - will warn us when one of these problems threatens to "complicate" things:

​Spinal Stenosis often overlaps with HNP and the two may exist together for years.  

​The primary findings that suggest that spinal stenosis will require a more extensive decompressive laminectomy are:

• Age > 50 y/o
• Pain is much worse in the legs when Standing  or walking, and improves quickly if you can just sit down.
• Sitting or leaning forward (“leaning on your grocery cart sign”) allows you to stay active without leg symptoms(picture)

​Degenerative Spondylolisthesis can cause severe stenotic symptoms along with LBP.  

​This condition usually results in specific severe low back pain due to deformity and instability, but if the "slip" isn't unstable the back pain may be more tolerable than the leg pain and decompression may be all that's necessary.

So what are the surgical options, if time, physical therapy, anti-inflammatory medications and injections haven't gotten us anywhere?

​The primary approach to a symptomatic HNP is through microdiscectomy.  This is a minimally invasive operation, routinely performed as an outpatient procedure, that removes the offending disc fragment, decompresses the nerve and removes any bone spurs that may be contributing to pain, without disturbing the adjacent joints or soft tissues important to spine function. 

​Carried out in most cases using an operating microscope and fluoroscopic imaging to confirm levels and alignment, microdiscectomy is highly successful with a very low incidence of serious complications.

It's minimally invasive, but it's not minor surgery, however. 

Microdiscectomy is performed through a 1 to 2-inch incision in the middle of the back, centered over the level of the disc herniation.

​After incising the skin, the back muscles are separated from the bony arch (lamina) of the spine and pulled to the side. These back muscles are held to the side with a special retractor or penetrated with a tubular retractor so they are out of the way during the surgery.

In many cases a small portion of the adjacent facet joint is removed to relieve any bone spurs putting pressure on the nerve and make it easier to remove the herniated disc fragment.

After the nerve is decompressed, a careful search is made to insure that no fragments are left behind.  The laminotomy is covered with a material to limit scarring, sometimes along with an antibiotic, and the procedure is over. The retractors are removed and the muscles fall back into place.

The patient is usually up at bedside within half an hour, and able to go home an hour or two after that.  Nerve pain usually improves quickly - sometimes right away - but may take a few days to weeks to get back to its best level.

​There are potential risks with any operation, and your surgeon will discuss those individually when you talk about surgery, but major complications are rare in the hands of an experienced surgeon.

So, How do you know when you Need Surgery?

When pain is intolerable, unresponsive to the non-operative therapies that so often help others, and is clearly related to a large disc herniation, then continuing to put off surgery can lead to nerve damage or scarring that make later treatment less reliable and more difficult.

It is appropriate to give non-operative care a real chance though, as most patients will see improvement in the first few weeks after an acute herniation and may never need an operation.  If symptoms persist, however, or nerve root or spinal cord compression is severe enough to cause weakness or disturb bowel or bladder function, surgery may be the most reliable and rapid solution to the problem.  

Whether it's a simple disc herniation treatable through microdiscectomy and laminotomy, or it's a more complex problem involving spinal stenosis or a spondylolisthesis, you will want to talk to a spine specialist about the option that suits your situation best.

Which is where I usually come in.  So, if you are having problems similar to this or any condition that you've been told will require surgery, and we are in your area, please feel free to contact my office for a consultation!

I hope you found this article interesting and informative. Follow me on Facebook to get updates on new content, and feel free to comment if you like this post or have other questions you'd like me to address.
 
Thanks Again!
​

​At the same time, we have developed better ways to treat bone disease and these fractures, allowing minimally invasive treatments that can prevent progressive deformity and speed healing and symptomatic relief.  So there’s rarely a good reason to treat these spinal fractures with what was once called "benign neglect".

​There are approximately 700,000 vertebral body compression fractures in the United States each year resulting in around 70,000 hospitalizations.  The most common fractures that affect our aging population occur in osteoporotic bone – bone that has lost some of its structural support and strength and some of its calcium mineralization.  Patients with osteoporosis, and those with metabolic bone disease (loss of bone mineral content due to metabolic disease) are at increased risk for a number of different fractures, but vertebral fractures are among the most common and, potentially, most disabling.

1. What is a pathological fracture?

​Fractures happen through any bone when the forces exerted on it are high enough to exceed its strength. This happens in automobile accidents, falls down the stairs, or poor decision-making on skis, skateboards, or bicycles, when normal healthy bone isn’t able to stand up to extreme loads.  These injuries often require surgical treatment because in these high-energy injuries the bone may be fragmented and the surrounding tissues traumatized.  These injuries are easily recognized, in most cases, and the need for treatment easily understood.

​Pathological fractures occur when the bone is not normal – it has lost much of its strength due to bone loss or mineral (calcium) loss or both – and it is liable to fail and fracture at much lower loads and forces, loads the normal body handles easily.

​Osteoporosis is the leading cause of the bone weakness that leads to these low-energy injuries, and it affects many older patients throughout the country, most of whom have no symptoms of pain or of impending danger until they experience a minor fall and break something.  Then it’s too late to take simple measures.

​2. What is Osteoporosis?

Osteoporosis is primarily a physical loss of bone structure – the struts and connecting pieces that make up bones internal structure get reabsorbed and removed from the marrow (trabecular) bone, progressively weakening the overall framework.

The bone that’s left behind is normal bone, mineral-wise, but there’s just not as much of it as there was when you were younger. Why would the body remove these important skeletal structures? Because the body is efficient and doesn't like carrying around stuff it isn't using!

If the patient has become less active, then the body has metabolic systems that will decide that not as much bone is needed to meet the daily physical demands.  The body is very frugal in some ways and will begin to remove the bone and mineral it thinks is excess from areas of lower load and either use it elsewhere or discard it. 

​This can happen at any age, and we do see this process in younger adults who spend time in a cast or in bed and can’t be as active as normal.  The difference is that young people catch back up quickly when they get back to activity.  In an older patient, who may have stopped exercising because of an arthritic hip, for instance, and then spent time in bed after another injury or illness, bone loss can be rapid and hard to recover from.

Illness, hormonal changes, or medication use can also affect bone strength, driving the loss of bone or depleting calcium and minerals away from the bone irrespective of activity or diet.  When all of this is combined with the loss of important hormones that naturally follows menopause in women, bone loss can be severe and pathological, or “fragility” fractures become common.

This is why bone health needs to be part of every woman’s routine medical follow-up and bone density (DEXA) scans should be periodically used to check for osteoporosis before it becomes severe.  That doesn’t mean men are off the hook!  Just that the problems are less common and tend to move more slowly in men as they age.

And, there are other causes of osteoporosis and fragility that can affect anyone, regardless of gender age or activity.  There are certain types of cancer that may severely weaken bone before they can be successfully treated with radiation or chemotherapy.  Many patients with inflammatory disease or different types of arthritis may require steroid medication that can cause severe osteoporosis.  And other medications and illnesses can do the same.  Some of these patients will experience vertebral compression fractures despite careful surveillance.

3. ​What is a Compression Fracture?

​Compression fractures are the most common and least dangerous vertebral fracture that we commonly encounter.  They are specifically defined as a fracture of the vertebral body that disrupts the anterior wall of the vertebral body, without disrupting the posterior cortex or pushing bone into the spinal canal.  The posterior elements are always uninjured, so the spine remains stable, and neurological injuries are very uncommon. 

​These fractures occur after an “axial-loading injury” – an injury where the forces applied to the vertebral body are directed straight down the spine and compress the vertebral endplates, the way a person might step on a pop can to try and crush it.  And the injury causes the bone to crush down much like that pop can – the top and bottom are left intact but the side walls collapse down, sometimes a little, sometimes alot!  

The vertebra shortens and tends to collapse into a wedge.  The higher the force applied, and the weaker the bone, the greater the degree of collapse and the weaker the bone, the easier it is to collapse the side walls in the first place.

​Most healthy people that have a compression fracture will get over the fracture pain pretty quickly, and the degree of collapse, if not severe to start with, will tend to stay stable and not progress.  The fracture will heal, pain will lessen and resolve, and the only long-term finding will be seen on future x-rays, where the comment may be “Looks like you had an old compression fracture”.  At that point the patient may recall something like “Well I did fall off the roof when I was younger…I was REAL sore for about a month, but I got better”.
However…

When osteoporosis is involved, that fracture force doesn’t have to be so great – “I just slipped off the stool I was sitting on!” – and the fracture is more likely to keep collapsing before it finally heals, which means the pain can persist for months.  Worse, the final healed spine can end up badly collapsed. 

​And that collapsed, wedged vertebra puts its neighboring vertebrae under increased stress which greatly increases the risk of another level experiencing the same fracture and collapse with the next minor fall.  This progressive, serial spinal collapse is responsible for the common hunched deformity seen in many elderly women, so uncharitably referred to as the “Dowager’s hump”. Not my terminology.

That progressive serial collapse has serious implications beyond just being painful.  The collapsed spine can collapse the chest cavity, compress the stomach region, interfere with breathing and eating, and seriously impact health and fitness!  And the persistent pain associated with these multilevel fractures and the spinal deformity may not go away once these fractures heal in such a bad position. 

​So we want to prevent that first fracture, and prevent it from collapsing down when it does occur.  And that’s where minimally invasive surgeries such as Vertebroplasty and Kyphoplasty come in.

4. Can Surgery Help?

Big open surgeries are rarely necessary or reasonable in treating osteoporotic compression fractures, but two minimally invasive surgical techniques - Vertebroplasty and Kyphoplasty  - have proven beneficial and easily tolerated by patients with persistent fracture pain and progressive collapse.  

​Both of these procedures are performed through a thin cannula (think fat needle) that can be guided into the fractured vertebral body under fluoroscopy.  

Once inside the fractured bone a doctor performing the vertebroplasty will inject the fracture region with a fluid form of polymethylmethacrylate – bone cement – to fill in the spaces between the pieces of broken bone and stop the collapse of the fracture.  The doctor will watch that cement flow carefully under fluoroscopic guidance and stop injecting as soon as the fracture region is filled in or there is any sign of leakage outside of the bone.   ​

​Through that same cannula system, a core of bone is removed or a pilot hole is made into the heart of the fractured vertebra.  Once that small hole is created, a specially designed “balloon” is advanced down into the bone cavity into just the right position.  Now, as the balloon is carefully inflated with a saline solution, the collapsed vertebra can be restored to a more normal height and the fracture corrected. 

​Because kyphoplasty allows the surgeon to create an open space where the fractured bone was, the cement is injected in a much thicker state, reducing the risk that it will leak out around the nerves or flow into the spinal canal.

​Again, at the end of the procedure the bone cement hardens and the patient awakens ready to get up and start back to activity without further restrictions.  The improvement is often remarkable – patients who were unable to get up and down from bed because of fracture pain can, after kyphoplasty, literally get up and make their bed.

5. What’s the downside to such a straightforward procedure?

​Fortunately, major complications are very uncommon, but since these procedures are often needed by elderly or frail patients, we take the risks of anesthesia and medication seriously.  Many patients will be kept overnight to insure there are no adverse reactions to the anesthesia. ​

​The most common complication of these vertebral augmentation procedures has been radicular (nerve) pain caused by migration of cement into the space around the spinal nerves. In most patients, small intradiscal and paravertebral leaks of cement have no clinical importance, but there have been case reports of severe neurologic complications, underscoring the need for appropriate technique and safeguards provided by skilled practitioners.  Permanent paralysis has been reported, but is exceptionally uncommon if the procedure is performed in a controlled, image-guided fashion (by using a bi-plane real time fluoroscopy unit).  The anticipated complication rate is higher when treating tumors (10%) than for osteoporotic compression fractures.

So then, Who needs Kyphoplasty?

Most compression fractures that occur in normal bone heal rapidly, without trouble.  And fractures in osteoporotic bone usually do as well...but they need to be watched.  ​

​If you have a compression fracture, diagnosed by x-ray after a fall, and you have osteoporosis or other risk factors, you should see your primary doctor back for a follow-up x-ray at 4 - 6 weeks to make sure the fracture isn't continuing to collapse.  If it is, then vertebroplasty or kyphoplasty may be needed to avoid progressive deformity and pain.  And, if you've had a fracture, and even though it doesn't seem to be progressing the pain just isn't going away either, this may represent another form of failed healing - a nonunion - that can be effectively treated with kyphoplasty.

In either case, it makes sense to see your spine surgeon for a consultation to make sure nothing has been missed. If you happen to be the one with the fracture, and you need to see a specialist, I'm glad to see you if we're in your area.

If that's the case, call 800 670-0302 to arrange an appointment!

I hope you found this discussion useful and interesting.  Please let me know if there are other topics you'd be interested in learning about, and check out my Facebook page for updates on future topics.