My patients love to garden, and no matter what - back pain, neck pain - nothing's going to keep them out of the garden for long.  But there are things you can do to keep your back and neck in good shape while you do that hard work you love so much!

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​Let me know in the comments if there are questions you'd like me to answer about your back or neck problems, or about spine surgery in general. And feel free to share this with others.

it is clear that the process is becoming so widespread that anyone can end up facing a denial for treatment – delaying care and requiring a formal “appeal” for almost any form of medical care.
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Different insurers handle the process different ways, but all use it.  Doctors continue to incorporate algorithms into their notes and documentation to cover every possible question your insurer could ask,  but, then, the insurer can always ask something else that has never come up before, or more commonly request written documentation from a third party to support the patient’s own report, in essence saying “Prove it!”.   And this denial of coverage often comes within 24 hours of the scheduled surgical date, making a response difficult, impossible, or fruitless.

The usual outcome is that your doctor will have to have a “peer-to-peer” conversation (argument) with another doctor (often retired, employed by the insurer), to convince them that the surgery is necessary and appropriate. Usually this is successful, but it helps (is absolutely necessary) if your doctor has ALL THE AMMUNITION he/she needs to win that argument.

Patients often assume that, for one reason or another, this won’t affect them.  Here are 5 (OK, 7) ASSUMPTIONS patients commonly make before getting DENIED by their insurance company:
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1. That won’t happen to me – I have really good insurance!  Pre-approval is a favorite tool of EVERY good insurance company, and they employ an army of reviewers and administrators to comb your records to see why (not if) they should delay or deny your expensive surgery.  Aetna, Anthem, Medical Mutual, HCA – doesn’t matter, they all do it, and some more aggressively than others. 
2. They can’t deny me treatment for a serious health problem! – They can and they do.  There was a time when I could document that a patient had spinal cord compression or early signs of paralysis, for instance, and get an approval without delay.  That’s not the case anymore.  In fact, the AMA reports that roughly 90% of doctors surveyed reported seeing patients whose critical treatment was delayed by pre-approval denials, and who suffered significant adverse events due to treatment denials.
3. I’ve done all the things a patient can do to get better, before seeking surgery – this should be straight-forward… Again, that used to be the case.  But as physicians have gotten better and better at adhering to original guidelines for approval, insurance companies have continued to “move the goal-posts”.  While spine care providers have long recognized the importance of active physical therapy, anti-inflammatories, activity modifications, and pain management as proper treatment before considering many surgeries, these were intended as appropriate ways to get patients better, and not hurdles to prevent surgery.  Now, however, many companies simply insist on these treatments, and want to see them documented, before approving surgical treatment of any kind. 
4. I had a complete, formal physical therapy program, gave rest, ice, nonsteroidal medications, and chiropractic treatment a reasonable chance to work!  Well, that’s where the Prove it! part of the conflict comes in.  When you get your denial letter, (often days after your surgery was cancelled) it will say that your surgery was cancelled because “your healthcare provider failed to provide adequate documentation” that you had met criteria for approval.  What that means is that, even though your notes document that you have had a “full course of physical therapy” and the appeal letter your doctor wrote documented the dates you had physical therapy, the company wants to see the actual records from your physical therapist!  Did you get those for your doctor? Do you have them at all?  Similarly, while your doctor is considered an expert in interpretation of x-rays and MRI everywhere else, including a court of law, their reading and report of your x-ray findings or your MRI can be dismissed as “inadequate” and the company will often demand the original radiologist reports from where-ever your imaging was done.  Did you bring those with you?  We will need them.

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5.  My health is at stake – surely they don’t want me to get sicker?  Remember this – your insurer didn’t say you couldn’t have surgery, they said they wouldn’t pay for it.  The AMA suggests that one of the proposed benefits of pre-approval denials – the prevention of unnecessary treatment and costs – often borne by employers, has not been seen, and that an additional cost of prolonged and sometimes permanent disability for their workers has now been documented, and attributed to either delay treatment, or patients’ frustration and decision to abandon effective treatment because of denials.  To that point the AMA survey  found that:

• 34% of physicians reported that prior authorization has led to a serious adverse event for a patient
• 24% of physicians reported that prior authorization delay has led to a patient needing hospitalization
•  18% of physicians reported that prior authorization has led to a life-threatening event or required “un-authorized” intervention to prevent permanent impairment or damage

If you don’t have the surgery, you may not get better, your employer may have to pay for disability or find another employer, but your insurer will get to keep the money they’ve already collected as your premium. And if you get sicker, your doctor can “appeal”, repeat the work that they’ve already done, reschedule your surgery and try again.  That’s not good for you!

6.  Well, as long as I get the surgery done, they’ll have to pay afterwards.  That’s not a reliable assumption even if you get the pre-approval in the first place.  Post-treatment denials are not uncommon and require a another round of appeals if your hospital is going to recoup the expenses of the hospitalization and surgery without turning to you. The denial letter will again refer to “your healthcare providers” either lack of documentation or a mistake in billing, but that mistake can consist of absolutely perfect paperwork being read incorrectly by the insurer – for instance a reviewer not recognizing the difference between arthrodesis (fusion) and arthroplasty (joint replacement).

7.   Well, if my doctor does a good job with the peer-to-peer review this should get settled pretty quickly, right?  Unfortunately, not so.  Roughly a third of the peer-to-peer reviews I engage in start with “So what did you call us for?” When I respond that I was offered a chance to appeal their denial decision I am informed that, no – I was offered a chance to call and discuss it, but that the denial was made based on “a Board decision”. I was informed that the company had decided at the corporate level not to cover that type of treatment and that there was no opportunity to discuss, appeal, or debate the denial.  “Thanks for calling”.  Or as one neurosurgeon/reviewer told me – “your right, there’s no reason to get an MRI for this patient’s compression fracture, but that’s our corporate policy.  She (the patient) must have an MRI and then resubmit the request”. They then refused to approve the MRI!

So, here’s my advice:
Get your records, keep your records, and copy your records like you were preparing for a tax audit.

Know who provided your care, when and where. Bring copies of your physical therapist or chiropractors treatment notes with you.

Don’t fudge the dates – if you tell me “sure – I’ve had a full course of physical therapy” I’ll believe you, but if it turns out it was three visits two years ago, there’s a real likelihood your surgery will get delayed or flat-out denied.

Don’t cut corners – if your doctor prescribes physical therapy but you just don’t want to go, there’s not much anyone can do if your insurer flags your chart.  If you do go, and it’s just too painful – GET YOUR THERAPIST TO DOCUMENT THAT CLEARLY – and provide that documentation when you come to see your surgeon.

Bring your imaging studies – x-rays and MRI – on a CD so your doctor can read them and plan the best treatment for you, BUT ALSO – bring the Radiologist’s printed reports for those studies so they can be submitted with your treatment application.

This was intended as a brief note, but so many of my patients are being impacted by this process now that it is crucial that you be prepared and understand the process a bit.  It won’t help to get frustrated with your doctor’s clinic staff or schedulers. They often fax 20 – 30 – 40 pages of material to your insurer, 2 or 3 times to make sure everything is in order...only to get a one page fax the day before surgery, without explanation, stating that the surgery is denied for “lack of documentation”.

And, if you end up embroiled in this process, this is one time that writing your senator and congressman wouldn’t be a bad idea, as these issues are being reviewed in congress.  Your story could be important to changing this system!

Thanks for reading, and let me know what other questions you might have!

If you’re looking for scientific papers on the subject, you can find over 150 peer-reviewed publications on Pub-Med or in the Scientific and Medical Journals that focus on surgical treatment.  But what if you just want to know what they look like and how they work?

Well, let’s break it down!
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What is an artificial disc?

An artificial disc is used to replace the damaged intervertebral disc that is removed during discectomy as treatment for a disc herniation or disc degeneration.  

Placement of the artificial disc, more commonly referred to as a disc arthroplasty or cervical disc replacement, fills the gap left when the original disc is taken out.  In so doing the artificial disc restores the original, normal disc height, holds the adjoining vertebra in normal alignment, and preserves a small amount of motion in flexion and extension, side to side rotation, and left and right side-bending – about the amount the normal disc had when it was healthy.
A spinal fusion – the traditional solution after discectomy – can do those first two things very well, but it eliminates all motion at that level, leaving the rest of the spine to take up the slack.
 
How does the disc replacement work?
The disc replacement device, or implant, is designed to insert into the disc space – the gap left after the disc has been taken out – with minimal removal of normal bone or ligament tissues, and is held in place with small teeth that grab the bone, and with the normal tension of the remaining soft tissues holding it firm.

The bone of the vertebrae will eventually grow directly into the top and bottom plates of the device making the fixation permanent, but right from the start the fit of the specific disc designs is such that loosening or slippage of the device is very rare, even with early motion and activity.  So, they don’t need to be screwed in or cemented into place, and you don’t need to wear a hard collar or immobilizer while recovering from surgery.
 
How are disc replacement implants designed?
There have been many different designs of artificial discs created over the last 40 years, and a lot of different materials have been tried from one time or another.  Spine surgeons have benefited A LOT from the much longer and sometimes fraught experience of our total joint colleagues who have been studying these issues for many decades longer.

The implant designs that I use now are all FDA approved, studied in numerous scientific trials, and have been in use around the world for at least a decade in each case, and much longer in some cases.

The primary design for each of the implants I use is the same:
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Each disc design has three parts: two metal plates – one top and one bottom - and a plastic insert or spacer in the middle. 

The plates are made of a mix of metals commonly used in spine and joint replacement surgery (cobalt, chromium, and molybdenum in some cases, and titanium in others).

The plates typically have either teeth on the top and bottom that help hold the plates to the vertebrae, or small thin “keels” that slot into the bone above and below. The teeth or keels are pressed into the bone without any bone removal, which makes the implant designs I use easy to place properly, without cutting away normal bone.

The surfaces of the top and bottom metal plates are typically sprayed with a coating of a bone forming material (hydroxyapatite) that stimulates the vertebral bone to grow and attach to the metal plates for long term stability.

The plastic insert that fills the space between the plates differs from implant to implant.  In most implants the insert is made from a high molecular weight polyethylene, a material with enough density to resist wear and deformation over time, but “slick” enough to provide very little friction as it slides back and forth against the upper and lower plates. This is the same strategy and material used in our most successful and long-lasting hip and knee replacements. The insert is designed to move a little back and forth and side to side as you move your neck, mimicking your natural joint motion.

How big is the implant?
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They come in different sizes, in order to properly fit different size patients. (Interestingly, your body size does not necessarily tell me much about the size of your spinal elements: some very big people have a surprisingly small bone structure, and vice versa!). 

Typically, though, the implant is not much bigger than the size of your thumbnail, and not taller than two or three quarters stacked together.

The four disc replacement implants I current use are all FDA approved and well-studied across the globe.  Full disclosure – I have been asked to teach surgical techniques to other surgeons from time to time, and I do participate in Investigational trials for some implants ( I was a Principle Investigator for the original MobiC two-level FDA study 15 years ago, and am an investigator for Centinel Spine’s two-level Investigational Device study now), but I am not a paid consultant for any of these companies.

​So, I can honestly say I pick the implant that suits my patient’s situation best, each time!

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​MobiC – ZimVie is a new name for a long-established company, and the most widely used two-level implant in the US.  You can learn more about their implants here.

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Pro-Disc-C – One of the first to bring an artificial disc to the lumbar spine world, they have a long-established and successful product for single level surgery, and Centinel Spine is sponsoring an ongoing investigational study for their new implants for two-level surgery.

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M6 – Provided by Orthofix, this implant has a unique central core that also provides a little more cushion, in theory, than the solid high molecular weight polyethylene cores, and fits certain disc configurations very well.

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Simplify – A newer entry provided by Nuvasive, this implant has titanium plates top and bottom, which eliminates any concern for those with metal allergies, and is approved for two level use.
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Thanks for reading!  I hope you found this both interesting and informative.  Feel free to Like and Share this content and please comment to let me know what other questions you might have!

Disc replacement surgery represents a powerful, well-established tool for treating disc herniations and cervical disc disease in selected patients.  That’s good news for patients who have persistent pain and dysfunction due to neck pain, who still want to avoid a spine fusion if they can.
 
So, what’s the role of Disc Replacement Surgery in 2022?  There’s good news and bad news…

​Good news!! Most patients with neck pain recover without surgery:  80-90% will get better, and 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!
 
Bad News!!  About 10-15% of patients with a serious neck problem will eventually need surgery.  They’ll need an operation to relieve persistent arm pain due to a herniated disc, arm pain and weakness due to nerve root compression caused by disc degeneration, or surgery to treat instability or deformity.
 
When persistent neck and arm pain are annoying, we can treat those well with a number of different non-operative strategies – physical therapy, manipulation, oral medications, or injection therapy.  But when pain is bad enough that it interferes with daily function, employment, fitness, sleep…surgery starts to make sense.
 
Who needs spine surgery?
We consider surgery for patients who have structural neck pain problems, such as disc degeneration, instability, deformity or more serious issues such as fracture, infection, or tumor.  We also depend on surgery as a reliable solution for many causes of arm pain or weakness (radiculopathy) including disc herniation, cervical stenosis, or segmental instability.

​Not every type of operation works for each of these problems, though, and each has its strengths and its drawbacks.  Disc replacement surgery is an excellent treatment for disc herniations and disc degeneration, but 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 suffer neck and arm pain due to disc degeneration or herniation, disc replacement – or cervical arthroplasty – is an important option.

Who needs disc surgery?
Degeneration of the Intervertebral Disc causes changes in disc, which sits between each of the vertebral bodies and acts as a shock absorber and slightly flexible joint.  As we age, the molecular components of the disc change, resulting in a loss of water-holding capacity, and a progressive loss of elasticity and compressive strength – the disc becomes a less successful shock-absorber.
 
On x-rays we see:
Bone spurs (osteophytes) form around the facet joints and edges of the discs themselves
Disc damage that causes bulging and herniation
Loss of normal mechanical stability, loss of disc height, and loss of normal neck posture
We can even see structural deformity
 
These changes go along with the symptoms we see:
Axial neck pain – pain in the muscles and ligaments of the neck, stiffness, shoulder and back pain;
Referred pain - symptoms over the trapezius, rhomboids, and shoulder blades
Tension myositis - muscular pain, often causing headaches; and
Radicular pain - pain in the spinal nerve distribution causing pain down the arm and into the hand and fingers
 
Radicular arm pain is the symptom most commonly requiring surgery.
When these symptoms are severe, interfering with fitness health, and normal rest, and when they fail to improve after a good trial of non-operative care, that’s when we consider surgery.
 
The general rules for choosing surgery for a patient start with the symptoms:

• Arm pain not responsive to a good trial (3 months) of conservative therapy
• Any progressive neurological deficit
• A persistent neurological deficit with persistent radicular pain
• A surgically correctable lesion has been confirmed on imaging studies
• Any progressive instability or deformity

​The traditional treatment for cervical disc herniation is an anterior cervical discectomy (surgical removal of the disc) and fusion (ACDF).  That’s a surgery through the front of the neck, through which the disc is removed all the way back to the spinal canal. 
 
But, why fuse the spine after you get the disc out?

​The interbody fusion (placing a cage or bone between the endplates of the adjacent vertebrae) restores intervertebral and foraminal height, immobilizes the painful segment, and provides permanent stability.

But it 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 would otherwise need a fusion. 

​The approach for the disc arthroplasty, and the removal of the damaged or herniated disc is exactly the same as in the traditional ACDF procedure, but instead of placing bone or a fusion cage in the empty disc space, disc replacement surgery replaces the damaged intervertebral disc 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. 
 
Who is a good candidate for a disc replacement?

• Patients with at least 6-12 weeks of persistent pain, that hasn’t responded to a good trial of conservative therapy
• Patients with radicular 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 still demonstrate 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.

​What about older patients? If patients are reasonably fit, and bone quality is good, age isn’t a big factor! Studies of disc replacement have included patients up to age 69, and my experience with patients older than this suggests disc replacements are just as successful, and better tolerated than the traditional fusion.

What about activity level? Patients that are athletic or hard working can depend on disc replacements to hold up to high demands – they are not fragile.

What about smokers? Well, first off – stop! It’s not good for you.  However, smoking does not affect the outcome of disc replacement surgery the way it can a fusion, so disc replacement is probably a better choice for you too.
 
 
Here's the caveat:

• Any recommendation of surgical treatment should be about selecting the best option for each individual patient, considering their particular symptoms and challenges, and their age, health, and demands.
• The surgeon’s job is to offer the treatment that carries the highest likelihood for treatment success and the lowest risk of serious complications, again considering each patient’s  particular circumstance.

 
With that in mind, cervical disc arthroplasty offers 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.  And feel free to like and share this content with others that might find it beneficial!

Back and neck pain are common problems that most all of us will experience at one time or another.  However, the cause of each person’s pain and the way it affects their life and function can differ significantly.  One of the most common causes of failed spine surgery and failed back care is failure to make the correct diagnosis up front, and the subsequent failure to provide the best treatment thereafter – doing a surgical procedure that wasn’t helpful or failing to operate when someone really did need it. 

One of our most important tools in medical diagnosis – of any kind – is called the “History”.   Without a good history, we tend to make assumptions, and if they are the wrong assumptions then we can start down the wrong path when it comes to treatment. That can lead to delays in recovery, unnecessary procedures, or a poor outcome all together.

No one wants that!

So, your doctor will want a full and accurate history to help them understand what your particular problem is and how it affects you, so they can provide you the very best and most specific care.
 
Here are Six Questions you should be able to answer for your Back Doctor when you come to talk about back and neck pain or back and neck surgery:


1.  What can I do for you today? “Just fix me” sounds cute, but it’s not a helpful answer.  Tell me what brings you in today – “I’ve had back pain for years, but for the last 3 – 6 months I’ve been getting terrible leg pain and it worries me” or “ I’ve been diagnosed with a neck strain, but it’s not getting better and my doctor thinks I need to see a specialist”.  It’s OK to say “I’m not interested in surgery, I just want to make sure it’s not something serious!”.

2.  Where does it hurt? – Sounds simple enough, but every day I meet patients who said “neck pain” on their intake form yet immediately describe burning pain running down their arm to their hand as their real problem.  This is important information and it’s important to be thoughtful and specific in your description. 

And, if the answer changes with activity or time of day that’s important too.  “When I first get up my pain is right in the middle of my back – low down, but after I’ve been up and standing, it starts to run down the back of my legs to my feet and toes.  Is that weird?” No – it’s important information.

3.   How bad is your pain? This is always a hard question to answer, because we each experience pain in different ways at different times.  The best way to measure pain is sometimes in terms of what it prevents us from doing.  If the pain is severe enough that it’s interfering with your ability to sleep, exercise, and/or work, that’s important. If non-operative treatments don’t get you significant relief, surgery might be a serious consideration.

If it’s keeping you from enjoying more than three or four rounds of golf each week, that’s important too, but it suggests you’re functioning pretty well, and a sports/rehab approach might be right for you!

4.   How long have you been having pain?  It’s important to be clear – I recently had a long conversation with a patient who reported that her pain had started “about three weeks ago”. After looking through the patient’s records I asked why they had had previous x-rays and MRI studies. “Oh, I’ve had back pain for years. But this time it’s been going on for three weeks”.

​It’s okay to be a little more detailed – “I’ve had back pain for years, but the leg pain didn’t start until the last six months, and it was just last month that it became severe and the numbness and tingling started”.

5.   What have you been doing to treat the pain?  Your doctor will want to know, and your insurance provider – Medicare, Medicaid, or any other – will quite literally tick off the boxes on previous treatments before they approve any surgery, injection therapy, or even an MRI.

“I take an anti-inflammatory medication regularly, with some benefit.  I’ve had a complete course of physical therapy, starting in…and ending in…(know the dates), and it didn’t help me much”, or “I tried to do physical therapy, in …(know the dates), but it made my pain worse and I had to stop”. If you’ve had injections or other treatment, make a note of when that was, where it was, and who your doctor was. 

“I’ve had injections recently, but they didn’t help or at least not very long.  They were done by Dr. …, and they were epidural injections/selective nerve root blocks/trigger point injections/facet blocks…”.  If you’ve had a previous operation, who did it and what did they do? 

Bring records with you when you can.  When insurance companies deny treatments or demand an appeal for treatment, it’s usually based on lack of previous treatment or lack of documentation of previous treatment.

6.  Are you working at your regular job right now?  This isn’t just a question about your insurance, but one about how your pain is disrupting your life.  “I am not working at my regular job, which involves a lot of bending, lifting, or twisting, but my company is great and they’ve got me a light duty job that’s easier to do” is a completely different answer and situation from “ my boss hates me and says I can’t come back unless I can go back to the loading dock”.

But it’s just as important to know that, if you work in the home, you can’t carry a load of laundry, pick up your children or do your household tasks.  In either case it’s appropriate to ask the question: Do you need a back operation, or do you need a better job or more help in the home?

Making a correct diagnosis and putting together a sound treatment plan depends on understanding where your pain is coming from, how it’s affecting your life and impairing your function, and understanding whether it’s likely to respond to a program of non-operative treatments and therapy or whether there is likely to be a need for surgery. So don't get frustrated with all the questions - it's your chance to guide your doctors in the right direction.

​If you can provide a clear and accurate History for your doctors, its much more likely that you’ll get the care you need, when you need it, with the best possible outcome.

Thanks for reading!  Feel free to Like and Share this content and let me know what other questions you might have!

​So, please be careful…I want you to be active, but take care of your back and use good common sense!
 
I hope you find this discussion interesting and useful.  If you have 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 beneficial!

While all the other terms are different ways of naming irritations, sprains, degeneration or nerve problems in the extremities, all of which can be cautiously observed and conservatively treated, myelopathy means injury or illness of the spinal cord, a crucial and sensitive structure that doesn’t always recover from injury, and of which – you only have one!

What is myelopathy?  Myelopathy occurs when the spinal cord is injured or damaged by severe compression resulting from trauma, spinal canal narrowing (stenosis), degenerative disease, or disc herniation, or by more uncommon but emergent problems such as infection or cancer.

​The spinal cord is the one structure that carries nerves the length of the spine to deliver sensation to the brain and carry muscle impulses to the limbs. When any portion of the spinal cord becomes compressed or constricted, the resulting symptoms of numbness, weakness, and loss of coordination are known as myelopathy.

While neck pain and strain, and even arm pain and numbness can be watched for a while, because they often get better on their own or with supportive therapy, the compression of the spinal cord has to be looked at differently. When a nerve in the neck is compressed, even severely (causing arm pain or radiculopathy) there is a very high likelihood it will recover after surgical decompression, even if the pressure has been there for a long time.

The spinal cord is not so forgiving – prolonged pressure on the spinal cord can result in slow, progressive changes that will not respond to non-operative therapies and can become permanent and completely unresponsive to late surgery.  Even worse, a severely compressed spinal cord can be permanently and completely injured by even a minor trauma like a slip and fall or minor motor-vehicle accident.

​In those cases the spinal cord may be permanently damaged, leaving the patient partially or completely paralyzed (quadriplegic) for life.

What are the symptoms of myelopathy?

They’re a bit different from common neck strains and “pinched nerves”.  While radiculopathy causes weakness of one arm (or leg when it happens in the lumbar spine) it also causes severe arm pain, which is the thing that gets most patients off their couch and on the way to the doctor, no matter how nervous that makes them.

Myelopathy puts pressure on the spinal cord and may not irritate the nerve roots at all.  In this case, there may be no severe pain. No arm pain and no new neck pain. Only diminishing function – decreasing strength in both legs.  Numbness and tingling in hands and feet, mild at first.  Loss of coordination and balance.

​These symptoms are frequently misdiagnosed by friends and neighbors, spouses and colleagues, and our doctors, as neuropathy (are you diabetic?), arthritis (got bad knees?), old-age (how old were you last year when you didn’t have these symptoms?!?), or more rarely as a serious neurological disorder such as multiple sclerosis or one of its related conditions. In fact, it is fear of the MS diagnosis that sometimes makes patients hesitant  to seek a full evaluation.

​The symptoms patients may become aware of include neck pain and can include arm pain, but also include spinal cord specific symptoms:

• Loss of hand and arm coordination and manual dexterity (can’t button buttons, handwriting is deteriorating)
• Loss of balance and coordination (can’t walk a straight line, can’t walk across the room in the dark)
• Disturbances of bowel and bladder function (incontinence, insensitivity to urination)
• Spasticity (increased reflexes)
• Numbness, tingling, or weakness of both legs or arms ( a pinched nerve affects just one side)

​Sometimes the lack of pain creates another problem that patients have a hard time wrapping their head around: “Why do I want to have (a sometimes big) surgery when I’m not having any pain? And HOW, if I have neck pain after surgery, am I any better than I was before surgery?

Reasonable questions.

The best answer is in understanding the goals of treatment.  In benign problems like arthritis, and disc herniation, our goal is to relieve pain and restore function.  A good result will reduce neck and arm pain and get you back to good function, and any post-operative pain is usually much less than what was going on before surgery.  So patients are happy.  

​With myelopathy, our goal is to take pressure off of the spinal cord and prevent paralysis! That often requires a fairly extensive operation, and there is often a degree of post-operative pain and stiffness that the patient has to work through.  And, if all goes well, as it usually does, the biggest bonus is that nothing bad ever happens.  Sometimes it’s hard to appreciate that the reward for all this hard work and anxiety is: “I’m not worse!??”
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However, worse is sometimes terrible, and your surgeon’s job is to protect you from that in any way possible.

So, what is the treatment for Myelopathy?

The first step is to establish a firm diagnosis. This is actually pretty straight-forward.  A typical MRI study will reveal the level and degree of cord compression, if there is any, and will tell us something about the health of the spinal cord itself, providing guidance as to whether this is something we can cautiously plan for, or whether the problem needs to be addressed as an impending emergency.

And the treatment?
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Spinal cord compression requires physical decompression.  That means surgery is the only way to physically take the pressure off of the cord and restore its normal function. 

​Steroids – sometimes wonderful for radicular arm pain – will have no long-term benefit here.  Traction, manipulation, physical therapy – can’t change the spinal canal diameter, and can even injure the at-risk spinal cord.  Medications may mask some symptoms but won’t change the situation.  And this is one of those times when time is not on your side: early treatment is more successful, less risky, and less challenging.

Spinal decompression may be offered through an anterior approach – through the front of the neck – removing herniated discs, disc osteophytes (bone spurs), or entire vertebrae; through a posterior approach (laminectomy) taking the roof off of the spinal canal and decompressing the spinal cord; or frequently may require a combination of the two. These are challenging operations, and almost always require a spinal fusion, immobilization, and post-operative therapy.

If your doctor comes to the conclusion that you have spinal stenosis, or a disc herniation, cervical stenosis, or any other problem causing myelopathy, this is the right time to arrange a consultation with a spine surgeon – even if that’s scary – and not the time to put things off.  

​The good news is this: with proper treatment spinal cord compression can be relieved - “cured” - and spinal cord function can be preserved and often restored if caught early enough.  Post-operative neck pain can be minimized and controlled.  And return to normal activities and even sports and recreation are possible.

So, ‘myelopathy’ is that one word (diagnosis) that should catch your doctors eye, and should get you on your way to a specialist evaluation and early treatment without delay.  And if you have any of the symptoms I’ve outlined here, don’t hesitate to ask your doctor or therapist directly – “Could this be signs of myelopathy?”
 
I hope you find this discussion interesting and useful.  If you have other questions that I can answer for you, please comment below.  And feel free to like and share is content with others that might find it beneficial!

 When your back hurts it is hard to get moving.  Most patients with back pain worry that activity will aggravate their problem, and many fear that it may actually harm them.  For the vast majority of patients, nothing could be further from the truth! 

Daily activity, and a regular aerobic exercise program, are the keys to getting most people back to good function and are important even in patients that may someday need surgery.  Time invested in a physical therapy and exercise program is never wasted.

​The easiest way to get started with an exercise program is by walking.  Walk a bit every day and try and get out at least 3 times a week for a longer walk, and walk quickly for half an hour to 45 minutes.  If you're doing it right you should get a little sweaty.  Exercise on a treadmill, elliptical trainer, exercise bicycle or in a swimming pool are all good, particularly if the weather outside is nasty.

 Patients with narrowing of the spinal canal - spinal stenosis - may find walking difficult.  These patients may find an exercise bicycle much easier to exercise on than any upright devices such as a treadmill or elliptical.  Patients with disc-related back pain may find sitting on a bicycle difficult, on the other hand, and be more comfortable either swimming or walking. 

Find the exercise you can do and do it 3 times a week. 

Start with 5-10 minutes of exercise at a time and work up to 30-45 minutes as you are able. Do not get alarmed if you get a little sore after exercising.  Keep at it: Moderate exercise will not damage your spine.

 Back exercises

 Pelvic tilts
 Lie down flat on the floor or an exercise pad and bend both knees.  Start by tightening your abdominal and buttock muscles.  Rotate your pelvis and hips slightly towards the ceiling and press the small of your back against the floor.  Hold this position for a moment and then relax.

​ Partial sit up
Laying on your back with both knees bent and your feet flat on the floor, fold your arms across your chest or over your tummy.  Tighten your abdominal muscles to raise your chest and shoulders just off the floor. 

Don't strain your neck; keep it straight. 

Hold your back and shoulder blades off the floor for a count of 3, then relax and let yourself back down.  Take a couple of deep breaths, and repeat.

​Full Sit-ups

 For patients with better starting muscles who want to get stronger abdominal wall and pelvic girdle musculature, a full sit-up from the flat position, with the knees bent and the feet anchored, works the deep muscles of the hip flexors as well as the abdominal muscles that help support the spine.

You can do these with your hands reaching for your knees or crossed over your chest.   Do three sets of ten – fifteen, and see how your back feels before trying to do more.

 Hamstring stretch

 Starting flat on your back, with your knees slightly bent, gently flex your hip and bring one of your knees up towards your chest.  Holding the knee with your hands, gently pull it towards you until you can feel a stretch.  Holding the leg flexed up in that position, straighten the knee out as much as you can, feeling the muscles stretch behind the knee.  Lower that leg slowly back to the floor then stretch the other side.

​ Wall slide

Find a nice, smooth section of wall, with a stable place to put your feet.  Do not try this on a throw rug or something that might slide!

 Start with your feet shoulder-width apart, about a foot out from the wall.  Lean back until your shoulder blades and buttock are resting comfortably against the wall.  Now bend your knees and hips and slowly slide down the wall into a half-sitting position.  Pause, then slide back up to your starting position.  As you slide, feel your back pressed against the wall.  Tightening your abdominal muscles as you move.  Your hips should stay higher than your knees, and your knees should not go out beyond your toes.

 Press ups

 Start by lying on your stomach.  Put your hands on the floor on either side of your shoulders.  Raise your head up and looked towards the far wall. 

Straighten your arms and push your upper body up off the floor.  Keep your hips in contact with the floor and arch your back.  Pause, then slowly bend your elbows and relax your tummy and chest back down to the floor.  Don’t go further back than you are comfortable going – this shouldn’t cause sharp pain, so if extension hurts you, you can skip this one.

Arches

 Start in the same position that you did with the press ups.  This time tuck your arms by your sides, and do not use them to push up.  Tightening your back muscles and lift your chest and shoulders up off the floor, again raising your head to look towards the far wall.  Hold this position for a count of 5-10, then relax back to your starting position and take a few, well-earned deep breaths.

These exercises will take you 10 – 15 minutes to do each day.  Do them each day if you can, but at least four times each week.  Do each exercise move 5 times to start, and 10 times each after you get used to it.  Move slowly, deliberately, and feel your muscles tighten as you do them. For the Stretches and Press-ups, you should feel stretching, but not sharp pain.

If you feel sore after exercise, that’s normal.  Use some ice on the sore-spot, use your anti-inflammatory medications, and go easy the next day.  If you experience sharp pain, stop your exercises and note which one seemed to aggravate things. Touch base with your doctor if the pain doesn’t calm down over 48 hours.


​I hope you find this program helpful.  If you do, feel free to share with others, and let me know if you have other questions I can answer.

 

Whether ​you are coping with an acute back injury or long-standing pain, here are some basic recommendations for good health and good spine health, for dealing with pain and starting to get better.

First, start with…

3 things that can help with your overall health:

 Weight control and fitness

 Controlling your weight and maintaining a good diet will contribute to your overall well-being and will help with reduction of pain in your neck and your lower back. Maintaining a healthy diet, avoiding overeating and snacks, and maintaining a good balance of protein and carbohydrates, will help you heal an injury, and maintain a good healthy fitness level.

 Smoking

 Cigarette smoking (it’s the nicotine!) is very addictive and it is hard to quit. Nonetheless, stopping smoking can be one of the most important things you can do for the fitness of your spine. Patients with severe back and neck problems really need to stop smoking, as the effect of nicotine on surgical treatment can be very harmful.

 Exercise

 Diet alone will not keep you from gaining weight, or help you lose it. A good exercise program is always important. Whether or you use an exercise bike, elliptical trainer, treadmill, or swim, walking remains one of the easiest and most effective ways to lose weight and maintain fitness.

​Now, things you can do to minimize or relieve your back pain:
Good body mechanics

Learning how to sit, stand, and move the right way is important to good back health, and very important to getting over a back injury.  Good back and body mechanics reduce the strain on back muscles during normal activities, and help you get back to normal activity without stirring up more pain than you need.  Moving the wrong way can be one of the reasons you strained your back in the first place, and it can really slow down your recovery.

Sleeping and laying down
Pain at night can really interfere with rest and recovery.  Both leg pain and back pain can be more aggravating at night.  If you sleep on your back, put a pillow under your knees, keeping your feet elevated and your hips and knees slightly flexed.  When you lay on your side try bending your knees slightly and put a pillow between them to keep your hips even.

 
Sitting
Make sure your chair supports your back well.  Your head should line up over your hips, and you should not feel like you’re slouching.  Support your lumbar curve with a rolled-up towel or lumbar roll just behind your back.  Your knees should be level with your hips. 

​You should take time to change positions and get up and stretch or walk around every half hour or so.

 Standing
 Standing in one spot is not a mechanical problem for most backs, BUT most of us find ourselves bending forward over our work for long periods of time.  Whether you’re doing the dishes, tuning a car, painting a picture or working at a tool bench, that partially flexed position taxes your back muscles and leads to stiffness and pain.  Bending your knees slightly will take the stress off your lower back but you can’t stand like that very long.  Standing with your foot on a small stool, or even resting it on the floor of an opened cabinet - while working at a counter or sink - will flex your hip, straighten your spine, and take some of the stress of the lumbar musculature. 

Remember to wear good quality shoes with a solid arch support.  Change positions and move about from time to time.

 Bending and lifting

 Always use good back mechanics when lifting: Don't cheat!  Whether you’re picking up a sock or a rock, bend at your knees and hips instead of your waist.  Keep your head and shoulders balanced over your hips and feet. 

Lift with your legs, not with your back.  Whether you are picking something up off the floor, or a tabletop, or a counter, keep the item close to your body and avoid reaching.  And remember, lifting at awkward angles is always a bad idea: Whether you are pulling groceries out of the trunk of your car, or putting your toddler in the car seat, both are much harder on you back than lifting 20 pounds off the top of a counter.

​ Turning

Learn how to "move as a unit".  This means keeping your shoulders and your hips square as you move from place to place.  Twisting a little bit to pick something up is not bad, but repetitive twisting back and forth is hard on your back.  When you move things from one place to another remember to move your feet as you turn, and not twist at the waist or knees.

 Reaching

Good back mechanics means learning how to protect your back whether you are lifting or not.  Bending at the waist and leaning forward puts a large strain on back muscles.  This is true whether you are tucking sheets on the bed, vacuuming under the couch, getting the milk out of the refrigerator, or lifting something out of your car.  Remember to bend your knees, keep your back straight, and work with your legs.

I hope you find this program helpful.  If you do, feel free to share with others, and let me know if you have other questions I can answer. Thanks for reading!
 
Thanks for reading!  Feel free to Like and Share this content and let me know what other questions you might have!

​But, because of national recognition, legislation, and some high-profile lawsuits, the government – and as a result your pharmacist – have put many changes in place that affect patients with back pain and neck pain who legitimately need those medications.

For doctors treating back and neck pain there is no way around it: while the most satisfying and rewarding part of our job is finding and correcting problems that cause pain, we still have to deal with the actual pain our patients experience before, during, and after surgery or other treatment.  As many spine fusion patients can’t take anti-inflammatory medications, we depend on opioid medications to get patients through the first two to four weeks of recovery.  That part of post-operative care hasn’t gotten easier as many of the promising “pain killers” of recent years have turned out to be real problems when they get into the wrong hands.

​Pharmacies, some of whom have been involved in large lawsuits, have been tasked by law to decide how much medication a patient can have, regardless of what your surgeon or physician has prescribed.

In Ohio pharmacies have adopted the legislated practice of providing no more than a seven day supply of any narcotic/opioid medication, limiting the daily dose, and cannot provide refills.  These rules apply to any patient being treated for “acute pain”, whether that acute pain is the result of an ankle sprain or a spinal fusion.

State-wide surveillance systems monitor exactly how much of any “scheduled” medication every patient receives, how often, prescribed by whom, and picked up where.  This report is “required reading” literally, for anyone writing you a pain prescription!

​There are three things we know about opioid pain medications that can’t be argued: 1. Long-term pain pills are a terrible treatment for ongoing musculoskeletal pain. 2.  The longer you take pain pills, the less affective they are, the more pain you feel, and the higher the doses you need to get any relief. 3. After a while, your body will just need the pain pills, whether you have a “pain generator” or not.  They are all addicting.

The laws on dispensing opioid medications are pretty hard and fast, and the penalties to your doctor or pharmacist are severe, so there is no wiggle-room here:
How can you avoid getting your pain medication prescriptions all messed up?

1. Be straight-forward and open with your pharmacist. Any dishonesty, or perceived dishonesty about what medications you’ve been taking, have recently taken, or what happened to your last prescription will get you “flagged” and your prescription may be denied.
2. Even if it’s the perfectly appropriate pain medication, never take medication from someone else’s prescription, or obtain medication in an inappropriate way. This will get you “flagged”.
3. Avoid seeking prescriptions from multiple different doctors over a two-year period.  After an acute injury and surgery you may have gotten a prescription from your family doctor, another from your Internist, one from the surgical resident, and one from your attending surgeon at the time of discharge – and you are on the borderline. Add one extra trip to the ER and you could be flagged!
4. Treat your paper prescription (“script”) like it was an important document – it is! Any evidence that the prescription has been altered – the dosage or number of pills changed, or the signature messed up – may mean the script won’t be accepted.  AND – going forward – Ohio pharmacies will no longer be accepting paper scripts except in unique circumstances.  Check with your pharmacist before surgery to find out whether an electronic prescription is needed for your post-operative medications. 
5. Understand that, if your medical or pain specialist doesn’t follow the rules, they can lose their license or worse.  If you are already in a pain management program, coordinate your post-operative pain medication management with them.  They can provide medication for chronic pain conditions that your surgeon cannot. At the same time, if you pick-up additional prescriptions from your surgeon that they don’t know about it can violate your “contract”. If that happens your source for long-term medication may be dried up, and when you go to any other doctor they will refuse to refill any of what your previous specialist considered legitimate.

Finally, its important to know that – when used appropriately – the most common opioid pain medications are safe and effective.  The two most common, hydrocodone (Norco; Vicodin) and oxycodone (Percocet, Roxicet), can be taken over the short-term with little risk of problems.  Recent studies have shown that, while these two drugs are the “most commonly abused”, they are also among the “least addictive” of the opioid pain medications we can use for acute pain. The reason they are recognized as being such a problem? – they are far and away the most commonly prescribed and readily available in the community.

That means that – after surgery or a severe injury – you needn’t be afraid of taking prescribed medication to make your pain manageable and make it possible to get up and around and rest comfortably at night.  Your pharmacist will make sure you are not getting too much.  When your pain calms down, take less.  When your pain is tolerable, stop using them altogether.  And never share medications with another person, leave your medication where someone else can get at it, or leave it where children or visitors might find it.

​Thanks for reading!  Feel free to Like and Share this content and let me know what other questions you might have!