Patients Recover Sooner from Minimally Invasive Back Surgeries

By Pat Anson, PNN Editor

A new study comparing short-term outcomes of minimally invasive lumbar decompression surgeries to minimally invasive spinal fusions found no significant difference in the amount of time patients needed to return to work. But decompression patients were able to drive and stop taking opioid pain medication sooner than the fusion patients.

Researchers at Hospital for Special Surgery (HSS) in New York City found that it took 117 decompression patients a median of three days to discontinue opioid medication, while it took a median of seven days for 51 spinal fusion patients.

It took 88 decompression patients a median of 14 days to resume driving, while it took 18 days for 45 fusion patients.

The findings are noteworthy, according to Sheeraz Qureshi, MD, an HHS spine surgeon, because a standard open spinal fusion generally entails a much longer recovery and slower return to activities than a standard lumbar decompression.

“Our study is the first of its kind to look at return to activities and discontinuation of narcotic pain medication after single-level lumbar decompression or single-level lumbar spine fusion performed with a minimally invasive technique,” said Qureshi, who was senior investigator for the study.

“All the patients in both groups were able to resume driving and return to work within three weeks of surgery. When you compare this time frame to that of standard open spinal fusion surgery, it’s really striking. Patients having a standard spinal fusion could take six months or longer for a full recovery.”

Degenerative conditions of the lumbar spine, such as a herniated disc or spinal stenosis, are common causes of chronic back pain. Patients may consider surgery when conservative treatments such as medication and physical therapy fail to provide relief.

Lumbar decompression surgery involves the removal of a small section of bone or part of a herniated or bulging disc that is pressing on a nerve. Spinal fusion is more extensive surgery, and is performed to stabilize and strengthen the spine. Surgeons join two or more vertebrae together, sometimes using screws and connecting rods.

In recent years, minimally invasive (MI) spine surgery has gained in acceptance and popularity. The technique uses smaller incisions than standard surgery and aims to minimize damage to nearby muscles and other tissues.

Although MI decompressions and MI fusions use the same initial approach to reach the spine with the same size incisions, the fusions are still more extensive surgeries, so pain medication may be needed for a longer period of time, according to Dr. Qureshi.

This study findings were presented at the annual meeting of the American Academy of Orthopaedic Surgeons.

What Back Pain Sufferers Should Know

By Doug Beall, MD, Guest Columnist

Allow me to describe a common patient referred to my office. Their back pain has been around long enough to be chronic and anti-inflammatory pills no longer dilute the pain.  Good days are when the patient is able to leave the house and painfully make it through eight hours at work; bad days are when the only endurable position is to lay flat at home all day.

Learning to live with the pain is no longer an option, so his physician refers him to my office. Let's pause the story here.

This sequence has been the experience of countless patients suffering from back pain. After months — sometimes years — of what feels like a 10 on the pain scale, these patients are willing to do almost anything to make the pain go away.

By the time they come to the doctor, most have done their research and have already written their own prescription, concluding that invasive surgeries and painkillers are the only options strong enough to alleviate their pain. But how did we get to the point where the all-out attack option seems like the only option?

As a doctor who specializes in treating patients for back pain, here’s what I wish more patients suffering from chronic pain knew.

When it comes to strong painkillers and increasingly invasive surgeries, bigger is not better. While surgery is the right option for some, the culture of pain management in the United States has produced the myth that the more invasive and aggressive the technique, the more effective it is. This over-reliance on aggressive techniques, especially opioids and invasive surgeries, puts last resorts at the front of the line while ignoring a range of safer and frequently more effective treatments — injections, vertebral augmentation, stem cell therapy or radiofrequency ablation, to name a few.

Simply put, the more aggressive and invasive techniques have not demonstrated that they produce better results. People aren’t automobiles. Our bodies can’t be put back together quickly or without some downside from surgery. While the more invasive repair may be better for your car, when it comes to people, the less invasive the technique, the better the patient recovery will be.

The primary consequence of the bigger is better mentally has produced a dangerous dependence on opioids for treating non-cancer pain and post-surgical pain. Opioids may be necessary for a relatively comfortable recovery after surgery, but normally not for more than four to six weeks. Recent research published in the Journal of the American Medical Association (JAMA) estimates that six percent of patients prescribed opioids after surgery become persistent opioid users. Chronic opioid use has ruined countless lives, so any treatment relying on opioids should only be considered a last resort.

Furthermore, it’s not clear that invasive surgeries are effective for patients. As an example, one of the most common pain management procedures is lumbar spinal fusion surgery, which is often used to treat chronic lower back pain. A new study from the medical journal Spine indicates 20 percent of patients undergo another operation within four years of an initial spinal fusion. Patients can only hope they’re not the unlucky one out of five sitting in the doctor’s waiting room who will be back for a second operation.

Pain sufferers should know that the vast majority of their chronic pain could be helped with simple, less invasive procedures without having to make an incision. When patients are referred to my office, I start with the least invasive options before moving on to surgery and more definitive techniques.

Instead of having patients go under the knife and prescribing them opioids, many of my patients suffering from chronic lower back pain have experienced tremendous results with radiofrequency ablation, which uses radiofrequency energy to deactivate a nerve that transmits pain from a patient’s lumbar disc.  This procedure can be done with a needle during an outpatient visit, and it often provides instant relief that can last for years.

Other procedures include epidural steroid injections (ESIs) and vertebral augmentation surgery. Both are minimally invasive options that help relieve acute and chronic pain.

Epidural injections relieve a variety of conditions, including sciatica, herniated discs and spinal stenosis. During an ESI, a surgeon or interventional pain physician injects a local anesthetic and a steroid into the epidural space, providing swift pain relief for the region. While this relief only lasts for a few weeks or months, it provides patients with enough time to continue working on their physical therapy and for the underlying pathology to heal.

Vertebral augmentation is an injection of a cementing agent into a vertebra in order to stabilize a vertical compression fracture (VCF). VCFs can result in severe deformity and extreme pain, and vertebral augmentation can help fix this injury with minimal complication or risk.

For patients suffering the disabling effects of chronic back pain, it’s important to know there are alternatives to opioids and invasive surgeries; not only radiofrequency ablation, but a whole range of minimally-invasive techniques. In the end, surgery may be necessary — but for many, these other options will prove to be not only safer, but also more effective.

(Editor’s note: For another view on ESI’s and their risks, see Dr. Margaret Aranda’s column, “5 Things to Know About Epidural Steroid Injections.”)

Dr. Doug Beall is a Fellow of Interventional Pain Practice, a Diplomate of the American Academy of Pain Management and is the Chief of Services at Clinical Radiology of Oklahoma, specializing in interventional musculoskeletal care.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

New Device Makes Back Surgery Simpler (Video)

By Pat Anson, Editor

Human trials are set to begin in Australia on a new spinal fusion device that could change the way degenerative disc disease, stenosis and other types of severe back pain are surgically treated.

Traditional spinal fusions usually involve several metal rods, plates and screws to hold vertebrae in place, while a bone graft grows around them.

“Existing methods of spinal fusion use rod or cage systems that require screws to be drilled into the spine and a painful bone graft harvested,” said Professor Bill Walsh, Director of Surgical and Orthopaedic Laboratories at the University of New South Wales (UNSW). “These systems are very costly, difficult and time consuming to implant and they also have relatively variable rates of fusion success.”

Walsh and his colleagues at UNSW have invented a device they call the Thru-Fuze, which is designed to make spinal fusions much less invasive. Only a few inches long and made of titanium, Thru-Fuze has a porous design that allows the patient's own bone to grow through it, without the need for grafting or other metallic hardware.

Bone grafting – a transplant of bone from another part of the patient’s body – often fails to achieve a complete fusion. And it can take up to a year to find out if the surgery was a success.

In laboratory testing on animals, spinal fusion with Thru-Fuze began in as little as six weeks, with bone growing on and through the device in what it's developers call a rapid “biomechanical” fixation.

This video was produced by USNW to explain how Thru-Fuze works:

SUBSCRIBE to UNSWTV : http://www.youtube.com/user/unsw?sub_confirmation=1 Thru-Fuze, a new UNSW "spine-welding" invention for the treatment of chronic back pain will be tested in world-first human clinical trials, following a $1.59m grant from the NSW Government's Medical Device Fund. Professor Bill Walsh, Thru-Fuze inventor and Director of Surgical and Orthopaedic Labs at UNSW explains how it works.

Human trials of Thru-Fuze are expected to begin at Prince of Wales Hospital in Sydney next year with funding from a $1.5 million government grant. Intellectual Ventures, a private equity company, has also provided funding and has exclusive licensing of Thru-Fuze. Patents for the device have been filed in Australia, Europe, China and the United States.

Lower back pain is the world’s leading cause of disability, according to the Global Burden of Disease Study.