Joey Wahler (Host): Some who've gone through one spine operation, wind up having another. So we're discussing whether you need a second spinal surgery. Our guest, Dr. Khalid Kurtom, he's a Neurosurgeon at U. M. Shore Medical Group. This is Live Greater, a University of Maryland Medical System podcast. Thanks for listening. I'm Joey Wahler. Hi there, Dr. Kurtom. Thanks for joining us.

Khalid Kurtom, MD: Good morning. How are you?

Joey Wahler (Host): Good yourself.

Khalid Kurtom, MD: I'm doing great. Thanks for having me.

Joey Wahler (Host): Thanks for hopping aboard. So first just how common Doc, is a second spinal surgery. And in a nutshell, before we get into some further details, why would someone need one?

Khalid Kurtom, MD: So actually spinal surgery is very common. Most people that have back or neck problems, I would say 95% of them, usually can avoid spine surgery altogether with conservative management. The few that end up in surgery, they're at a higher risk for having future spine surgeries. And we looked at the data of why these people have a higher risk than others.

And there's really no factors that are associated with a higher risk of having spine surgery. We looked at body weight, work, family history, etc. And, nothing really panned out. And these are large scale studies. But it does demonstrate that people that have an initial spine surgery, usually are at a higher risk for having future spine surgeries, whether it's the neck or the lower back.

And if you had an initial spine surgery, the chance of you having further degeneration in the spine that may be considered in the future for surgery is one in four people over a 10 year period. So it's not very uncommon, but it does occur.

Joey Wahler (Host): So what symptoms indicate that a second spine surgery may be needed for someone?

Khalid Kurtom, MD: So let's start with the initial surgery. After the initial surgery, most patients have a period of recovery. And after that period, usually they're well on their way to doing well and back to work and back to their normal function. In a short period of time after that, if they experience deterioration, of their back pain or neck pain or neurological complaints in the arms and legs, that could indicate failure of the initial operation.

If they had a fusion, for example, they may need to have a revision of their fusion operation. Down the line, years later, patients can have a completely separate issue somewhere else in their spine that presents in a variety of ways, whether it's neck pain or lower back pain, arms or a leg pain symptoms, sensory motor deficits, you know, weakness, numbness in the arms and legs can all amount to needing another evaluation, to rule out another spine issue that may need to be addressed.

Joey Wahler (Host): So it might be revisiting the first procedure or possibly having a second new one all together. Is there a rough average time frame of when one or the other might pop up time wise?

Khalid Kurtom, MD: Yeah. So if you've had a spine fusion operation, for example, the timeframe for hardware failure is usually in the first few months to a year after surgery where the fusion doesn't take, and you need to have a revision of your initial operation. After that period, anything that occurs after that, typically is associated with a another problem.

Most of the time it's adjacent level disease. So, whatever area that had the surgery before, the chances are that the area above it or below it are now giving you issues. And that's usually after the healing of the initial operation, which is about a year to a year and a half after surgery.

Joey Wahler (Host): So that begs the question, of course, if needed, how would a second spine surgery be different from the first?

Khalid Kurtom, MD: So obviously with the first operation, there's a period of recovery and with that recovery, there is a period of physical therapy, time off work, needing to get back to normal functional activities and that period for the second operation usually is a little bit longer because the body takes a little bit longer to recover after a second injury.

We look at surgery as a type of timeline where there's an injury that occurs, we know that we're trying to fix something, but in that process; you are exposing the body to an injury. So the period of time that takes to recover from that is usually longer. There is more scar tissue. There is more physical, need for muscle recovery. And, it takes a little bit longer. So, in preparation for a second operation, most surgeons have a much more detailed discussions with patients about what to expect at the second operation, which it should be more than the first operation.

Joey Wahler (Host): So how about the procedure itself the second time around? You mentioned earlier, for instance, some may need it because a spinal fusion didn't take as well as it could have. So as the surgeon, what are you doing differently or better the second time around?

Khalid Kurtom, MD: So it all depends on what the second operation is trying to accomplish. So if it's fixing the initial operation, so if it's in that time frame, right after surgery, where hardware is failing or disc reherniates, et cetera, you're going back in there and reopening that area and, adjusting the hardware or doing more of a decompression.

And sometimes you're doing a little bit more to add more strength to the construct or the hardware. So most of the time if, the issue is the initial operation, failing, then you got to do a little bit more in the second operation to fix that issue. Now, if the issue is something more than the first operation, so let's say you recovered, a year, a year and a half, two years later after surgery, and now you have a separate issue; now you gotta address a second issue, and sometimes that means extending the area that you operated on the first time, to involve the area above it or below it, and sometimes you have to go to a whole separate approach to deal with it.

It all depends on what you're trying to address, but the bottom line is you have to address the pathology that's presenting itself the second time around. And sometimes you have to tie it on to the first operation as well. So, just adds up to more extensive operation, than the first time around in most cases.

Joey Wahler (Host): about, is there anything ,patients can do on their own to minimize the risk of needing a second operation after having the first?

Khalid Kurtom, MD: I think that has a lot to do with following the recovery protocol from the first operation. So, when I operate on my patients, post operatively, no matter what, they're always in some sort of therapy program. They're always in a strengthening program for their core and their arms and legs.

I encourage all my patients to lose weight, if they're overweight, stop smoking, nutritional and exercise habits have to develop, changing things that could be causative factors; lifting wrong or body posture that's wrong. So if you follow those instructions after the first operation and you follow those protocols, you're giving yourself the best chance of avoiding further operations down the line and further issues down the line.

Now, if you don't do those things and you just expect the first operation to do all the work for you, well, there's a chance that that may fail or you may have another issue down the line.

Joey Wahler (Host): I presume, correct me if I'm wrong, that all, if not most of the list of things you just mentioned that would help ward off a second spine surgery could also help ward off a first one to begin with. Right? Like you mentioned there, for instance, lifting incorrectly, and I guess you mean whether it be just lifting a box out of your car or doing a squat at the gym. Oftentimes people don't pay enough attention to keeping too much stress off the back. Am I right?

Khalid Kurtom, MD: Absolutely correct. And it's unfortunate that it takes an operation to alert you to issues that may be causing harm to your body. And a lot of patients, are cognizant to the fact that they have had bad work habits or bad lifting habits or they smoked for a long time or they've been overweight.

And once they get to an operation, it really is an eye opening experience for most patients and end up, changing their entire life around, for the better, and by the way, we're just talking about the spine in this podcast, but a lot of the things that we're discussing are actually very beneficial for your general health overall. Cardiac disease, diabetes, et cetera, hypertension, all of those things can be helped with all those measures as well. So it's a total body reformation in most cases.

Joey Wahler (Host): Yeah, I know oftentimes when I'm working out, especially as I've gotten older, anytime I'm doing anything with weights where I'm standing, one of the first things I try to check and then maintain throughout the exercises are my knees bent because that's a big key and keeping too much stress on the back. Am I right?

Khalid Kurtom, MD: Perfect. You're basically referring to axial loading. Axial loading, think of your spine as one column and by the way, the spine is connected to your hips and knees and ankles. So if you're loading your joints straight up and down, that is the worst thing you can do for your joints and for your spine.

Having a strong core, whether it's stomach muscles or back muscles, to kind of hold you up so that you're not putting all the pressure on the spine. Having a little flexion in your hips. A little flexion in your knees. Where you can use your muscles and not load your joints. All of those things for the long run are going to be very helpful to avoid having surgery on those body parts.

Joey Wahler (Host): Definitely great stuff to keep in mind. Couple of other things you touched on earlier some statistics concerning the success rate of first spine surgeries that might require a second. How about the success rate for a second one?

Khalid Kurtom, MD: Clearly less than the first one. So every single time that you have surgery, your first chance at the fastest recovery with the least amount of complications is your first operation. Anything that you do after that, there is more recovery time, more risk involved in the actual operation and more risk involved in not fully recovering all your symptoms after that operation.

So, it really behooves us to avoid surgery altogether by doing all the right things. But if you are going to have surgery, make sure that that experience it's a life altering experience where you come out of it with every intention to avoid any future operations.

Joey Wahler (Host): Understood. Are there those that need a third spine surgery or perhaps more beyond that?

Khalid Kurtom, MD: Unfortunately, yes, on the record that I've, had, I've seen somebody that came to me from out of state who's had 10 operations. And that's been my record. And I know there's other surgeons out there that have had patients with more of a surgical history than my experience.

And the unfortunate thing in those situations is also the timing of the first operation. So if you get an operation in your twenties or even teens, twenties, thirties, well, you still have a long life ahead of you to wear and tear your spine, where you would need to have further operations. Also the younger that you are, the more cautious you should be about, do I need to have an operation?

so when I operate on young patients, it has to be an absolutely, without a doubt, something that has to be done; because young people have a long way ahead of them. And if you open that door early on, there's a chance that you may have more need for further surgeries down the line.

Joey Wahler (Host): And so in summary, Doctor, if all goes well with a second spinal surgery, both on the procedure end and on the lifestyle end with patients doing what they need to do, as you touched on, what results can people expect in terms of quality of life going forward?

Khalid Kurtom, MD: It should be excellent. It should be excellent with every operation, to be honest with you. The main thing is number one, selection. Making sure that surgery is absolutely needed. So, if there is any other way around needing to have surgery, you should explore all the conservative options prior to having surgery.

If you are going to have surgery, prep for it appropriately. Whether it's the first operation, second, third, et cetera, make sure your body is in the right shape to be in, make sure that you do all your therapy, all the factors that can contribute to bad outcomes, avoid those factors or try to fix them.

And then after the operation, follow a regimen that will give you the best chance of having a healthy lifestyle. And I think if you do all of those things, you should expect to have a good outcome. I know this, most surgeons, it's not a technical issue with the surgery it's mostly, what happens before and after surgery that leads to the outcomes and where they end up.

So you should expect to have good outcomes with all the operations, with spinal surgery, if it's done appropriately, both by the surgeon and the patient.

Joey Wahler (Host): Well, that's certainly positive news. Folks, we trust you're now familiar with having a second spinal surgery. Dr. Khalid Kurtom, thanks so much again.

Khalid Kurtom, MD: Thank you for having me. This was great.

Joey Wahler (Host): Same here. And you can find more shows just like this one at umms.org/podcast, as well as on YouTube. Again, umms.org/podcast. And on their YouTube channel as well. Now, if you found this podcast helpful, please share it on your social media. And thanks again for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System.