Transcription:
Micro-invasive Spine procedures - Fact or Fiction

Scott Webb (Host): It's not often that many of us get to speak with a spine specialist about micro invasive spine procedures, spinal stenosis, lumbar and cervical disc herniations and so much more. But today I'm joined by Dr. Oren Blam. He's an Orthopedic Surgeon and Spine Specialist with the Centers for Advanced Orthopedics. Orthopedic Associates of Central Maryland, in practice for over 50 years.

I'm Scott Webb. And this is We've Got Your Back Bite-Sized podcast from OACM's back and management team. So Dr. Blam, it's so great to have your time today. I have some back issues myself, as many people do, I'm 53 and we want to know what's going on and, and, you know, the signs, symptoms and treatment options.

So as we get rolling here, let's do a little fact or fiction. Let's talk about micro invasive spine procedures, and maybe have you do a little fact or fiction, which is which, and I think that that'll be a good jumping off point for us.

Oren Blam, M.D. (Guest): Ah, I mean there are many different procedures we do for spine problems. We always try non-operative care first, but when non-operative care is inadequate, and if someone still has persistent pain in the back, neck, arms or legs, sometimes surgeries can help. In terms of choosing a surgery, there are procedures that have bigger incisions. There are procedures that have smaller incisions and this concept of microscopic or micro invasive procedures, is the idea that we try to use smaller cuts in order to achieve similar goals. I always tell patients the most important thing is to achieve the goal, that is to reduce pain by unpinching a nerve or by stabilizing the spine or by stabilizing or correcting a deformity.

These are the goals of the surgery. And if that can be done with a smaller incision, then so much the better, but that's always the main thing for the surgeon and the patient to think about is what is the problem and how are we going to fix it? There are some older procedures like microdiscectomies that have been around for decades that involve very small incisions achieve the goal of unpinching a nerve. And then there are newer procedures that also use smaller incisions, with special types of instruments that allow us to see deeply in the spine without necessarily having to do a big cut. So, there are certainly are some procedures that are considered microinvasive, but the most important thing is to address that goal of spine surgery. Sometimes the bigger incision is the better incision if it fixes the goal.

Host: Yeah, I see what you mean. And I think for all of us, for us lay people as non-experts in this, you know, some of the buzzwords there for us in medicine today are you know, micro invasive or minimally invasive, because we associate that with smaller scars, a quicker recovery time, less pain after surgery. Is that generally, like when we think about microinvasive approaches and when they're indicated, when they're appropriate, are those some of the things we should be thinking about that are the benefits for patients?

Dr. Blam: Absolutely less pain, easier recovery. That is the goal of less invasive surgery. But that goal cannot supplant the other goal of actually fixing the underlying problem. So, sometimes depending on a person's spine problem, a bigger incision is the better way to go. At other times, there are minimally invasive procedures we do that can really fix the problem when the problem is localized to one small area. So it all depends on exactly what the underlying problem is.

Host: Yeah, that makes sense. Like sometimes the micro minimally, the smaller incisions work, and sometimes, maybe what used to be the older gold standard, the bigger incision. That's what's indicated that's what needs to be. And as you say, your job as the expert, as the surgeon in the room, you're just trying to fix the problem, trying to get people back on their feet, back to their lives and all of that.

So I've got a whole list of things, Dr. Blam, that I want to go through today. I mentioned it before we got rolling here that I probably suffer from spinal stenosis. And my great aunt used to tell me, oh, well that's inherited, that's a genetic thing. It was handed down in our family. So one of my questions is, is spinal stenosis something that can be a part of our family history and genetics, but also really just have you tell folks, cause I, I hear that a lot. I hear spinal stenosis a lot, but what is it exactly. And what's your approach to care?

Dr. Blam: Spinal stenosis is basically a word that means less room available for the nerves. And that in part can be due to conditions that you're born with that can be passed down in families, basically a person's body shape, as you know can b similar to your parents and grandparents, on the outside of your body, but also on the inside of your body, your inside body shape, the way your spine is formed, can be a little smaller, or a little bigger, depending on your genetics.

And so you can be born with a tendency to develop spinal stenosis, but perhaps even more commonly stenosis can develop from age-related degenerative changes, things like disc bulging and bone spurs and thickening of ligaments, all these things that can happen with age can then lead to spinal stenosis. And many times one can have both a congenital problem you're born with and then aging on top of that can lead to pinched nerves.

Host: Yeah, see what you mean. So let's move on to a lumbar and cervical disc herniations. What's that mean exactly? And what do you do to help folks?

Dr. Blam: The discs you may know is a shock absorber between the vertebrae and as we age, they can sometimes degenerate and become stiffer, sometimes leading to pain, many times, not necessarily being painful, but occasionally a piece of disc can actually break off the mother disc. And that's partially, related to degeneration and partially sometimes related to a traumatic injury, lifting something the wrong way or falling or other reasons.

But when a fragment of disc breaks off the mother disc, it can sometimes push out of its normal location and stick into the room where the nerves are. That's called a herniation. When you have a disc herniation, the fragment of disc is pinching the nerve and that pinching of the nerve can lead to a lot of pain in the neck or back, and also can lead to pain, shooting down the arm or the leg.

Host: Yeah. And so, another one on my list here is the sacroiliac joint pain or buttock pain. I know some folks who have complained of this to me. And I said, you know, if I ever get an expert on, I'm going to ask them exactly what to do about that. So what can you do to help them?

Dr. Blam: Sure a pain in the butt is definitely a pain in the butt. I'll tell you. It can be chronic and quite bothersome. And it's actually a condition that's not been as commonly recognized over the years, it's perhaps becoming more and more apparent over the past 10 or 15 years as a condition. So people tend to, not diagnose that because it wasn't on their minds, but buttock pain can be due to a lot of reasons.

One of which is this sacroiliac joint, the SI joint. The sacroiliac joint is a joint in your pelvis between the middle bone of the pelvis, the sacrum and the side bone of the pelvis, the ilium. That SI joint usually does not move a lot in human beings. It's fairly rigid with very strong ligaments that hold it rigidly together. But sometimes for various reasons, the joint can become loose and the bones can rub on each other. And that can lead to a lot of buttock pain. Sometimes it can even cause some pain to shoot down your leg, mimicking a sciatica as if there were a disc herniation, when in reality it might just be the SI joint. And in that case, there are treatments to try to calm down the inflammation and pain in the SI joint, including anti-inflammatory medicines, physical therapy, injections of steroids, and then one can even consider a minimally invasive surgery to stabilize that joint.

Host: And, you know, it seems like an obvious sort of follow up, like, is there anything that we can do? You know, so I often wonder, you know, obviously there's surgical and non-surgical options. Are there behavior and lifestyle things that we can do? I mean, would it just help not to sit so much or to sit a certain way? Maybe just seems like such a pedestrian question, but I'm just like, I want to know, like with a lot of these things, what can we do to help ourselves?

Dr. Blam: The main thing is keeping good fitness of the back, pelvis, hips and thighs. That is, we want the abdominal and back muscles, left and right, front and back to be balanced. We want the ligaments around the spine, pelvis, hips, and thighs to be stretched and not tight and balanced. Same thing with the tendons in these regions, because these different structures around the abdomen, back hips, pelvis, thighs, they all work together as a unit to support the trunk.

And when they're imbalanced, the spinal pelvis can be twisted or torked causing strain on discs or the sacroiliac joint, or just the muscles and ligaments in that region. So keeping that area fit is helpful and that involves different kinds of stretching and strengthening exercises, avoiding obesity, avoiding smoking, which can accelerate degeneration of joints. These are all important things and when things kind of get imbalanced and painful, many times physical therapy can be helpful.

Host: Yeah. And I'm glad you mentioned PT. Cause that's one of the things that I had on my list today. So let's talk about that. The role and efficacy of PT, Physical therapy in treatment of radicular pains, or just in general with this whole laundry list that I have for you today? I know I have some experience with PT, my kids as well. They're just amazing, but I want to have you talk about how amazing they are in particular about all these back-related issues.

Dr. Blam: Physical therapy actually has a well over a 90% success rate for treating most neck and back problems because most neck and back problems are related to this imbalance of muscles and ligaments around the spine. So not everyone's going to get better with therapy, but a vast majority of people will, in order to rebalance the support structures of the spine. Therapy involves stretching and strengthening. Therapy can involve different pain management techniques to reduce the sensation of pain, including massage, electrical stimulation, sometimes dry needling when there's tightness, that's not being relieved with stretching exercises. They have various other modalities they do to try to improve the health of the support structures of the spine. It can be very helpful. Sometimes medications, especially early on in the course of someone's pain can also be helpful to allow a patient to participate better in physical therapy.

And sometimes injections, a way of delivering a medicine to the spine can be helpful. In the less common cases, surgery might be needed, but therapy has an over 90% success rate for most spinal conditions.

Host: That's amazing. That's certainly been the case for me, almost nearly a hundred percent in all me, and my family members who've been seeing a physical therapist is they're just so good. They're so knowledgeable, so effective. And can often, as you say, solve the problems, avoid surgery, which is great. I want to ask you about vertebral fractures, you know, because when it comes to like osteoporosis and things that happen to us in the natural aging process, or when we're deficient in some areas, right, is that we can injure ourselves or break things or fracture things when we really shouldn't, you know, I know of someone who was just walking down the hall and they banged their arm into the wall and they broke their arm. Okay. Well, yeah, it's a broken arm, but they shouldn't have broken their arm, but it was because they were deficient in something. So I wanted to ask you specifically, when do these fractures happen and is osteoporosis or other deficiencies, you know, typically the cause?

Dr. Blam: Osteoporosis, unfortunately, it's a very, very common problem. It's a disease where the strength of the bones is decreased and the bones become fragile, predisposing to fracture. It happens more commonly in women because women who go through menopause after around age 50, get a drop, a change in their estrogen hormonal levels. And that changes the way the body maintains the skeleton. So these thin bones are prone to fracture, and as we all know, fractures hurt and they hurt a lot. Vertebral fractures, are a relatively common area for fragility fractures to occur. And they cause a lot of difficulty.

The good news with vertebral fractures is many times those fractures may heal or solidify, with time and not necessarily with invasive treatments. It's just, we do supportive treatment, including medications, bracing, sometimes physical therapy. And that can help a lot of people, but there's a significant subset of patients who get these vertebral fractures who have such a difficult time getting out of bed, standing and walking.

And although pain may improve in the first several weeks after fracture, if pain is not improving, and if a person is unable to be mobile, they're essentially on bed rest for more than a few days that can lead to many other really bad medical consequences, pneumonia, bedsores, urinary tract infections, depression, difficulty eating, and people get a downward spiral sometimes from the severe pain. When that happens, or it seems like it's about to happen, we have another solution, something called kyphoplasty. It's a minimally invasive procedure with Twilight anesthesia, where we just put a needle into the broken vertebra and oftentimes we'll put a balloon into the bone to expand the bone from inside creating an empty space.

Then we remove the balloon and finally inject cement into the broken bone. That way the bone, the fractured vertebra is stabilized immediately and the person's back pain can be improved immediately. So that's useful when someone's pain is so severe that it's not improving early on. We can get someone up and moving and able to participate in physical therapy and mobilization.

Host: Yeah, it's good to hear that a lot of times they do heal themselves. And I just love how easily you explained that you explained, sounds like highly complicated procedure as if you were explaining how to make a sandwich. You're it's amazing. You just so you know, we just said we put a balloon in and the thing, and then, you know. Really, it's awesome to have your time.

Dr. Blam: I appreciate you saying that. I mean, surgery, is obviously complicated and that's why we go to school for so many years and have years of experience to get these things done. But like anything else that's complicated. We need to break surgery down into its different parts, get each part done correctly. And then the whole, ends up being a nice, straightforward procedure with great result.

Host: Yeah, well, we appreciate it. And you have such an easy way of explaining this to lay people. And even though I do host a lot of these, I've already learned a lot today. And as we get close to wrapping up here, I wanted to ask you about redo spine surgeries. You know, what's the redo rate, you know, how and when, and why does that happen?

And know, is that something that folks need to be as they approach perhaps their first back surgery, do they need to be thinking about, oh, well, if this doesn't go well, just maybe kind of put their minds at ease?

Dr. Blam: There are a lot of reasons why a person might need revision back surgery. I would tell you that, one thing to consider is the spine is really not just one organ we and common language or common experience. We think of the back as the back one thing, but in reality, the back is multiple levels. And so if you have a problem at one level L 5-S1, maybe you end up needing surgery for it. This herniation at L5- S1 that doesn't necessarily prevent you from having a problem at other levels of the spine. Similarly, I make a comparison to hip replacements. If someone gets, has arthritis and ends up getting a hip replacement on the right side, they may in the future end up meeting a hip replacement on the left side.

Not because there was a problem necessarily with the initial hip replacement, but just because another body system, the opposite hip broke down. That can happen in the spine. And so it's not necessarily appropriate to think of all revision surgery is being due to a problem with the initial surgery. But having said that, when we approach a patient, with a spine problem and they've had back surgery in the past or neck surgery in the past, certainly one of the things we need to evaluate is did the prior surgery have any issues that could have contributed? For example, a well-done spinal fusion can alleviate someone's pain, but does have a consequence of leading to increased strain at the level of the disc level, above or below, and then increased strain can perhaps increase the normal age-related wear and tear of the disc levels above or below and may predispose to things wearing out and needing repeat surgery at the next level up or down.

That's one reason why people are interested in a newer technology called cervical disc replacement. If someone has a neck problem, a cervical spine problem and needs surgery, although a cervical fusion can be very successful. Sometimes we may also want to consider a cervical disc replacement, which still achieves the same goals of the surgery to alleviate someone's pain, but then it preserves motion.

So as to avoid straining the next level up or down. But that is one thing to consider with revision surgery as to whether the first surgery had any problems. And of course, we need to look about mechanical breakdown and if we're doing a fusion, did the person actually fuse or is there a new problem there, the recurrent pain due to a biological problem where the person didn't fuse?

The other thing is when we do spine surgery, we always need to consider the alignment of the spine. We always want to keep the spine as a good alignment as possible. And sometimes if someone has surgery, but then doesn't maintain the best proper alignment, that can lead to, problems either with the same level or other levels of the spine breaking down.

So it gets complicated, but by doing a good history and physical exam, by checking x-rays and other imaging studies, we can usually come down to the root of the problem.

Host: Doctor, I really appreciate this. I found this to be so educational today. You make it sound so easy, but we know how complicated it is. And thankfully we have spine surgeons like yourself that we can be referred to and speak with. And thank you so much for your time today. And you stay well.

Dr. Blam: You too. Thank you so much.

Host: That was Dr. Oren Blam, Orthopedic Surgeon and Spine Specialist with the Centers for Advanced Orthopedics, Orthopedic Associates of Central Maryland, in practice for over 50 years.

Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. That's all for today. I'm Scott Webb and we've got your back.