Conquer Back and Neck Pain - Walk It Off! (22 page)

As we humans live longer and more sedentary lives, we become susceptible to all of these conditions. I am seeing more and more patients in their 80s and 90s who have a combination of degenerative narrowed discs, spondylolisthesis, scoliosis, spinal stenosis, and osteoporosis with kyphosis from vertebral fractures. They become totally disabled and some even become wheelchair bound because of neurogenic, arthritic, muscular, and mechanical pain. We can help some of these folks with modern spinal surgery, but it is much better to try to prevent these things from happening in the first place. We must teach our youth to exercise, take enough calcium, and never smoke! More will be said about measures to treat and prevent these painful conditions of the spine in
Chapter 11
.

Surgery for spondylolisthesis, scoliosis, kyphosis, and any combination of these spinal deformities is indicated when they cause chronic pain and disability. Deformities cause mechanical pain from instability, nerve pain from spinal stenosis, muscle fatigue pain from spinal imbalance, and arthritic pain from wear and tear on the small joints of the spine as well as the discs.

Spinal fusion is performed by grafting bone from one vertebra to an adjacent vertebra and allowing the bone to heal between these structures. Spinal fusion relieves mechanical pain by taking away the abnormal motion between the vertebrae. It relieves the muscle fatigue pain by maintaining correction of spinal balance, so that you are not leaning over all the time. And it corrects the arthritic pain by taking away the motion in the arthritic joints of the affected spine. Correcting the deformity and fusing the spine can also relieve nerve pain if, in the process, the spinal canal is opened up to some degree.

Today we have highly perfected metal implants that are effective in correcting the deformed spine and fixing it tightly until the bone heals and takes over from the metal. The implants are comprised fixation systems made up of any combination of screws, rods, hooks, wires, and plates, which can be made of stainless steel or titanium. These systems are designed for fixation of the spine at any level from your head to your pelvis, from in front, back, or side. They have revolutionized our ability to help people with terribly unstable and deformed spines regain a near-normal quality of life. Modern spinal fixation devices, along with MRI scans and modern anesthesia (more about this later), are the three things that have revolutionized the surgical treatment of most painful spinal disorders.

I should tell you more about the unfairly and infamously labeled pedicle screws because they have revolutionized our ability to safely stabilize the spine. These screws are placed in the pedicles or walls of the spinal canal to be able to attach one vertebra to another vertebra (see x-ray on page 86). Pedicle screws were made infamous in television ads aired all over the United States in the 1990s by lawyers who were soliciting cases for a class-action suit on behalf of patients who had received the screws in their spinal fusions. Allegedly the screws were placed in these patients without a United States Food and Drug Administration (U.S. FDA) new-device approval. Even though the case was eventually thrown out of court, the bad publicity surrounding the spinal screws had already unjustly scared patients concerning them. This is unfortunate, because sometimes the use of pedicle screws is the only reasonable way of fixing a painful spine deformity (see Figure B, page 86). I would personally choose to have pedicle screws placed in my back if I suffered from a problem in which they were indicated. I think they are a safe, effective, and sometimes the only way to treat some painful spinal deformities.

The standard source of the bone graft is from your pelvic bone, the iliac crest (more about bone grafts and bone graft substitutes in a moment). The bone graft is taken from one side of the back of the pelvis for spinal fusions performed from behind the spine and from the front of the pelvis for spinal fusions performed in front of the spine. A second incision may be required to take the bone graft. Many patients complain more about pain at the site the bone graft was taken from than at the site of the spinal fusion.

In patients who require long spinal fusions, particularly those with scoliosis, and in older patients with poor bone quality, it is sometimes impossible to obtain enough of the patient’s own bone to perform the fusion. For these and other reasons, bone graft substitutes have been perfected. The classic substitute for your own bone is someone else’s bone obtained from a bone bank (banked bone or allograft bone; your own bone is called autograft bone).

Banked bone has received a bad reputation in the United States because of the news of two patients who contracted HIV from it. The cases were the result of totally unacceptable tissue-banking practices. With modern tissue-banking practices, developed for the most part in our world-renowned University of Miami Tissue Bank, the risks of developing a disease after receiving banked bone are fewer than the risks from receiving your own bone! The risks from taking your own bone include infection, fracture of the graft site, bleeding, and other risks. I am not aware of a reported case of a disease transmitted from banked bone grafts obtained from a qualified U.S. FDA–certified bone bank.

Banked bone has been shown to be as effective in obtaining a solid spinal fusion as your own bone, although the rate of fusion is slower with banked bone. The advantage of using banked bone over your own bone is that the surgery is faster, there is less blood loss, and you can use as much bone as is required. The quality of the bone may be better than your own bone, depending on your age and health status. The cost of banked bone is about the same as your own bone when you factor in the surgical cost of obtaining the bone graft from your pelvis. Consideration of the cost of grafts for spinal fusion is important when you consider the many bone-graft substitutes that are now available.

The most high-tech of the bone graft substitutes is genetically engineered bone morphogenic protein (BMP), a naturally occurring protein in your body that stimulates new bone formation. Genetically engineered BMP is now available for spinal fusion. It is as effective in producing a spinal fusion as your own bone. The big problem with it is that it costs more than $4,000 per spine level fused, compared to approximately $300 per level fused with your own bone or banked bone.

Spinal fusion is performed in three major ways. The most common way is by placing bone graft from behind on both sides between the transverse processes (bones that project to the sides of the boney arches behind each vertebra). This is called a posterior lateral fusion (see illustration page 84). The second way to perform a fusion is to place blocks of bone between the vertebrae themselves from behind, called a posterior interbody fusion. This type of fusion is only performed in the lumbar spine (see illustration page 86). The third type of fusion is performed by approaching the spine from the front and placing bone blocks between the vertebrae (anterior interbody fusion). This is the most common way to perform a fusion in the neck. Fusions from in front require removing the disc between the vertebrae and replacing it with a block of bone or a hollow metal cage filled with crushed bone or a sponge with genetically engineered BMP. The combination of a metal bone cage and BMP is very expensive, as you can imagine (more than $7,000 per level fused). Blocks of banked bone work just as well to maintain the space between the vertebrae and fuse them together, and they are a lot less expensive ($600 per level fused). Banked bone blocks have the additional advantage of having the same consistency as your vertebrae. The metal cages are too stiff, and it has been shown that they do not give as much pain relief as banked bone blocks.

Spinal fusions performed from behind require an incision over your spine, be it neck, chest, or low back, depending on where the fusion is indicated. Fusions between the vertebrae of your low back require an incision on your belly. To perform a fusion from in front of your thoracic spine requires in incision between the ribs adjacent to the level that is to be fused. And an intervertebral fusion in the neck requires an incision in front of the neck alongside your windpipe (trachea).

The type of fusion required to relieve your pain depends on many variables. The decision to fuse your spine with or without metal fixation, the type of bone graft to use, and the approach from behind or from in front should be made by a spinal surgeon based upon your circumstances. However, the decision to have your spine fused must be yours and yours alone. I show my patients their MRI scan and x-rays and explain what I think is needed to alleviate their painful condition. I specifically explain to them the need for metal fixation and the type of bone graft that I recommend. I explain the nature, benefits, and risks of the proposed surgery and answer all of their questions. The most frequently asked question is, “What would you do for your family member or yourself given my situation?” I affirm that what I am recommending to them is what I would personally have done if it was my back. I also tell them that, given the information that I have told them about the procedure, they must be the one to make the final decision to proceed. This process is called shared decision making, where the patient has all the facts from the doctor concerning the proposed surgery and makes their own decision based on those facts about whether to proceed with surgery.

You have undoubtedly noticed that I have discussed spinal fusion in conjunction with the deformities of the spine — spondylolisthesis, scoliosis, and kyphosis. No one can argue that spinal fusion is indicated when these conditions are the cause of or are contributing to your back pain. Intuitively it makes sense that if your spine is slipped, crooked, or bent over beyond the point of no return, something needs to be done to correct the deformity and stop it from getting worse. Why then the controversy over spinal fusion that you have read in the news?

Actually, there is evidence that too many spinal fusions are being performed. It is based upon population studies that show a wide regional variation in numbers of spinal fusions performed in North America. No one knows how many spinal fusions per capita is the appropriate number. But it is obvious that in some areas of North America too few people have this procedure and in some areas too many spinal fusions are being performed. Although healthcare planners and economists will eventually determine what the correct average number should be, that number still won’t mean anything to you. What matters is whether a spinal fusion is the right thing for you or whether it is unnecessary in your case. The only way to determine this is to find a qualified spinal surgeon who will take the time to thoroughly explain your situation to you and let you decide what is best for you.

In my opinion, the reason that spinal fusion has received a bad name and is controversial is that it has been used too often to treat chronic “discogenic” low-back pain. I will discuss this issue in more detail in the next chapter on chronic discogenic back pain.

Most people (like my father) who suffer from acute attacks of back pain usually end up treating themselves. In most cases, that’s perfectly all right. In between infrequent attacks they have little or no pain. The usual treatment is a short course of bed rest, anti-inflammatory medication, ice or heating pad, massage, and walking it off. These simple measures work for the vast majority of people. But what if your pain never really goes away? What if the attacks of severe pain keep recurring at shorter intervals? What if back pain is ruling your life? What then?

If you have suffered from constant or recurring episodes of back pain for more than three months, then you have chronic back pain. Disc degeneration is the underlying cause of chronic back pain when it results in disc herniation, spinal stenosis, or spinal deformity. But what if these conditions are not the cause of your pain? What if your doctor has not been able to pinpoint why your back pain is lingering on? What if all kinds of treatment have been unsuccessful? What do you do now?

Your first priority is to find out what is really wrong. Make sure your doctor has exhausted all diagnostic tests that are necessary. I frequently see patients with MRI scans (see section on MRI starting on page 52) that have been performed in an open scanner that are so unclear that they need to be repeated in a closed scanner. On repeating the MRI in a closed scanner, I can often detect a subtle area of nerve entrapment that explains the patient’s chronic back and leg pain.

I try to determine the characteristic of the pain. Is it neurogenic, from nerve entrapment; is it mechanical, from instability of the spine; is it arthritic, from facet joint arthritis, or is it discogenic, from the disc itself, (see
Chapter 1
)?

It may require that you have an injection of an MRI contrast dye with the scan to detect some painful conditions. Slow-growing tumors of the spinal nerves that cause progressively severe night pain and sleep disturbance can sometimes only be detected with a contrast-enhanced MRI scan. Good-quality MRI scans are very accurate in detection of most conditions that cause chronic back pain.

Another test that is used to detect low-grade infections, arthritic conditions, and tumors that may be the cause of chronic pain is a bone scan. This test is performed by injecting a short-acting radioactive chemical called Technesium into your vein, where it is taken up by the active bone-forming cells in your skeleton. You are then placed in a Geiger counter-type scanner that detects the radioactivity and turns it into a picture of your skeleton. If the bone-forming cells in your body are reacting to inflammation from arthritis, infection, or a tumor, a dark spot will show up in the picture of your skeleton. Some bone tumors (multiple myeloma, a cancer of the bone marrow) will inhibit bone-forming cells, which will appear as a hole in the skeleton on the bone scan.