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Chat 6/26/00:
Treatment for Spine Conditions |
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Moderator:
Welcome to the Pain Management program on WebMD! Our guest today is Robert
Pashman, MD, and the topic is "Treatment for Spine Conditions." Dr.
Pashman is a board-certified orthopedic surgeon practicing at Cedars-Sinai
Medical Center in Los Angeles. He has dedicated his practice to the
treatment and research of adult and pediatric spinal deformities, trauma,
tumors, and infections, and degenerative disorders of the cervical,
thoracic, and lumbar spine. He is a member of the North American Spine
Society and the Scoliosis Research Society. Welcome back, Dr. Pashman! |
Question:
First off, what types of conditions are we talking about when we refer
to spine conditions? |
Dr.
Pashman:
Spine conditions produce pain, numbness, and weakness, commonly in the
arms and legs, but also can cause pain any place in the low back. The spine
and its pathology can cause problems with nerves which cause pain in the
upper and lower extremities. That's what we're discussing in terms of spine
problems, and it's a broad, general topic which includes: Infections, tumors,
and curvatures of the spine. |
Question:
After having spine surgery -- rods, cages, screws, et cetera -- is the
pain ever expected to be completely gone? |
Dr.
Pashman:
That is an excellent question. I think once the spine has been deranged
in some way, either by injury, or even by surgery, that the goal of surgery
should be to improve a patient's function. The expectation of a 100% pain-free
result is in my opinion too high. Don't forget, 80% of the population,
without surgery, has low back pain at some point in their lives. |
Question:
My dad has four herniated discs with spinal cord compression. Is there
any treatment available? He has had no luck finding any. |
Dr.
Pashman:
The question is, where are the disk herniations at? When you say spinal
cord, that would include disc herniations in the neck and upper back If
that is true, that the herniation is pressing on the spinal cord, then
he needs to be evaluated by a spine surgeon for that problem. |
Question:
What is the latest treatment of protruding discs in an otherwise strong
and healthy 21-year-old female? Probably the result of years of high
jumping -- one protruding disk on each side of the spine. |
Dr.
Pashman:
Protruding discs, per se, do not cause problems, unless they are causing
symptoms, such as nerve compression or back pain. Most of the time, disc
herniations are self limiting in symptoms with approximately 80% resolving
spontaneously in four to six weeks after onset. If the disc herniation
is causing continual low back pain or pain in the legs that is not resolved
with conservative treatments, such as exercise and certain medications,
then certain surgical procedures may be indicated. A complete description
of cervical disc surgeries can be found on my website, www.espine.com. |
Question:
Should lower back pain radiate from there to buttocks, down to scrotum
and rectal area? |
Dr.
Pashman:
Yes, that can happen, depending on where the herniation is located in the
spine. The nerves that innervate the regions you've described can be caused
by a disc herniation. |
Question:
My husband got hit on the head with a beam from 30 feet up. It knocked
him to the ground hurting his lower back. A neurologist has been treating
him for six months with no help. Tests have shown four bulging disks.
When he stands for more than 15 minutes, his legs go numb. What should
we do now? He's on Workman's Comp but that can't be his options, rest
is not getting him well. |
| Dr.
Pashman: The answer to your question depends
on multiple factors -- the magnitude of the disc
herniations, the alignment of his spine, and the
nature of his symptoms. Without an accurate picture,
it would be hard for me to make this diagnosis, or
suggest a treatment from here out. If you would like
to send the films to me, I'd be happy to review them. |
Question:
Harvey asks: Read an article on your web site that deals with back pain
and that some of these injections that they put in our backs may also
cause a disease of some sort. I have all the symptoms that were mentioned
in this article. I lost the web page and wanted to finish it. I had
a 360 spinal fusion in 1997. I also found out that my SI (sacroiliac)
joint is out of line and I have severe pain in my groin area and burning
pain in my lower back over my left SI joint area and down my legs and
feet and toes. My doctor tells me everything is all right and the fusion
looks good. It has now put me out of work due to the pain. Another
orthopedist said I had SI dysfunction. What is this also? Please help.
Thank you. |
Dr.
Pashman:
SI dysfunction after fusion can be caused by multiple factors. It is possible
that if bone graft was taken from the pelvis to do the fusion, that this
bone graft harvesting can cause sacroiliac dysfunction because of the proximity
of the graft site to the SI joint. Also, fusions increase stress at other
joints, so it's possible that a fusion can increase dysfunction. I commonly
use an SI joint injection in an attempt to diagnose those types of ongoing
symptoms. |
Question:
I have been told I have a mild case of spinal stenosis but not enough to
cause scrotum and rectal problems. Are hips joints a source of concern. |
Dr.
Pashman:
This is a good question. Whenever a spine specialist evaluates a patient
for complaints of hip pain, or pain radiating into the groin, a differential
diagnosis of hip problems vs. low back problems should be evaluated. Most
spine specialists can differentiate problems of the hip with problems caused
by spinal stenosis. If, in fact, the diagnosis cannot be made of hip problems
based on X-ray or other imaging techniques, a numbing injection into the
hip may differentiate the two. |
Question:
I feel 60% better since my surgery. Do you think this is normal recovery?
Also disks remain at L3, L4; L4, L5; L5 and S1 and cages input with
an iliac bone graft. I had rods, cages, et cetera and fusion from L3
to the sacrum. |
| Dr.
Pashman: It may take up to one whole year
to fully enjoy the benefits of spinal fusion surgery. |
Question:
For surgery for scoliosis upper and lower, what surgery is the least noninvasive
and do you perform this surgery? |
Dr.
Pashman:
What do you mean by upper and lower? Scoliosis surgery has evolved since
the early 1950's when done primarily for polio. Since that time, the standard
has been combinations of hooks, rods and screws to correct the curvature,
and hold the correction until solid bony fusion occurs. Most of these procedures
were done through the back. Recently, there has been renewed interest in
approaching the spine from the front. Screws and rods are placed in the
front of the spine to hold the spine and create correction. An excellent
example is found on my website, www.espine.com under adolescent idiopathic
scoliosis section. More recently, people are attempting to put the screws
and rods in using cameras through small holes. This method is yet unproven
and will not become generally practiced until more experience is gained. |
Question:
What about an S-curve? |
Dr.
Pashman:
Most S-type curves can be treated by fusing one or
the other curve, because the second curve is termed "compensatory." In
patients who have true double major curves, where
the whole S needs to be fused, this type of curve
is usually not amenable to anterior only surgery,
and is commonly approached from the back. |
Question:
Are there any surgical treatments for arachnoiditis? |
Dr.
Pashman:
No. |
Question:
Do you perform anterior and posterior endoscopic surgery? Could you elaborate
on the procedure? |
Dr.
Pashman:
This is a very good question. There has been a trend towards using cameras,
or endoscopic surgery, to do fusions in the front of the spine. Compared
against more widely used methods, in which a small incision is made, and
the fusions are done open, the following comparisons can be made: Using
an open incision, the surgery proceeds faster, usually with less complications,
and is technically easier to do. Fusions done using a scope are generally
only applicable in the lumbar spine, to L5 - S1. It is my preference, therefore
to do what is called a mini-open procedure. After approximately 600 cases
with very few complications, I would have to state that currently, this
is the preferred method for doing this type of surgery. |
Question:
Can someone end up with RSD (reflex sympathetic dystrophy) after spinal
surgery? |
Dr.
Pashman:
Yes. RSD, or reflex sympathetic dystrophy, is a condition where chronic
dysfunction of a nerve : can cause swelling and pain in an extremity. The
exact reasons that this occur are unknown, but it is well reported and
defined in our literature. |
Question:
From what we understand, there is no way to surgically intervene if herniated
discs are in thoracic area, is this true? |
Dr.
Pashman:
Disc herniations in the thoracic area present in complex ways. If the diagnosis
is accurately made, and the herniation is causing nerve compression, then
the herniation can be approached surgically in multiple ways. The current
trend is to place a small camera into the chest and remove the disc herniation
this way. Because the chest is a large structure filled with air, it is
very amenable to this type of camera technique. This is currently the technique
that I prefer. |
Question:
What treatments are available for arachnoiditis? |
Dr.
Pashman:
Arachnoiditis is best treated by a specialist in pain management and, unless
it's associated with gross spinal instability or other nerve compression
disorders, it should not be treated surgically. |
Question:
Why does degenerative disk disease occur? |
Dr.
Pashman:
As the spine ages, water is lost from the discs. As the water is lost from
the discs, the discs start to have a change in their character and function.
This is why degenerative disc disease occurs. |
Question:
My son (33 years old and overweight) has myotonic dystrophy. He has some
neck pain and went to an orthopedic surgeon who did an MRI (magnetic
resonance imaging) and noted two herniated disks (C5/6 and C6/7). Surgeon
wants to operate (anterior laminectomy, I believe). My son is not a
trooper when it comes to pain management. My concern is about the surgery
in general, especially in light of his disease. What are the complications,
recuperation time, et cetera and if he lives alone, how will he take
care of himself while convalescing? |
Dr.
Pashman:
In reference to the procedures and recuperation time, the answer can be
found on my website, www.espine.com under cervical discectomy. The issue
of complications with someone with myotonic dystrophy may be unique to
his particular condition. Certain patients who have muscle dysfunction
can have a higher rate of a problem called malignant hyperthermia. These
things should all be discussed with their doctor and anesthesiologist prior
to surgery. It would be interesting to speculate that the weakness in his
muscles have caused increased mobility in his spine, which in turn could
lead to the disc herniations. But, it is absolutely critical that he be
checked for scoliosis, because disc herniations in the neck, myotonic dystrophy,
and scoliosis, can frequently occur together. |
Question:
What is the likelihood of disc pain years after scoliosis surgery that
did not exist before surgery? What is the likelihood of disc degeneration,
and how much of both pain and degeneration is attributed to the surgery
and is there any post operative treatment? |
Dr.
Pashman:
Excellent question. We know that the incidence of pain in the low back
correlates proportionately with the levels at which the scoliosis fusion
ends. For example, a patient who has a fusion to L4 may have a 60% to 70%
chance of having low back pain after surgery, whereas a fusion that ends
at L5 has a much higher chance. In short, the more free vertebrae below
a scoliosis fusion, the less chance of having spine generated pain subsequent
to surgery. |
Question:
I was diagnosed with spinal stenosis and degenerative disc disease in September
of 1999. In November 1999, I underwent bilevel anterior cervical fusion.
The results have been somewhat disappointing. I recently had a post-surgical
MRI that showed a protrusion on the left. I still have considerable
pain, but my surgeon seems to think that this is all in my head. I
am not able to work and my surgeon has advised me to apply for medical
disability retirement even though he thinks I am fine. This seems to
be rather a contradiction of opinions. I am at a loss. What options
are available to rid me of the chronic pain that I am in. |
Dr.
Pashman:
I suggest you get a second opinion. This can be obtained through the internet
at www.espine.com. This is an excellent question. |
Question:
Dr. Pashman, should people be wary of second opinions given out over the
Internet? |
Dr.
Pashman:
The only thing that is missing from an Internet-based second opinion is
physical contact with the patient. In this situation, most useful Internet
second opinions are provided under the following conditions: That a patient
has already seen a qualified spine practitioner, that the diagnosis has
already been made through physical examination and imaging studies. It
has been my experience that useful and accurate second opinions can be
obtained by obtaining the patient's history, all of their imaging studies,
and speaking to them on the phone. If a patient does not have a diagnosis
for their problem already, they should be skeptical of the outcome of an
online second opinion. |
Question:
My son has had three lumber punctures and there was no fluid. They said
they would try again in a few days. Why would they not be able to get
any fluid? |
Dr.
Pashman:
This occurred because the needle was not put in a position to get the fluid
out. I guarantee you that the child has fluid because the lack of fluid,
or CSF (cerebrospinal fluid), around the brain and spinal cord is incompatible
with life. |
Question:
Does that mean the doctor did not know what he was doing? |
Dr.
Pashman:
No. People have to realize that doctors have very difficult jobs. Many
times, fluids are difficult to obtain for any number of reasons. I do not
think that inability to get a positive puncture in any space in the body
totally reflects a physician's capability. |
Question:
I am a 48-year-old male with a 65% curvature. Eight to 10 years ago, it
was 50%. What is the likelihood of this curvature continuing? |
Dr.
Pashman:
Adult scoliosis progresses at approximately one degree per year. Since
you have already shown that your curve is progressive, there is a very
high likelihood that it will continue to get larger. I would suggest you
consult a spinal deformity expert because most progressive curves of this
magnitude will require surgery for control. |
| Moderator: We've
reached the end of our show. Thank you so much, Dr.
Pashman for joining us again! |
| Dr. Pashman: Thank
you, once again, for having me in this forum. |
Related links:
WebMD chat "Cage
Implants for Degenerative Disk Disease"
WebMD chat "Spine Surgery"
Listen to a radio interview
with Dr. Pashman, KFI-AM Interview "The
Lumbar Artificial Disc" 12/3/05
Why a Spine Surgeon
Back FAQ's
Obtain a 2nd Opinion
|
