Michelle Hughes has a high tolerance for pain. Which is a good thing, because Hughes has been dealing with back and neck pain every single day since her car was rear-ended while she was stopped at a traffic light, about five years ago.
The pain is always there, and some days are worse than others.
Hughes’ job is physically demanding — she's on her feet all day as one of the Eastside’s premier colorists at a leading salon. At today’s interview, she can’t feel her legs. Sometimes she gets excruciating headaches from holding her head in the wrong position. She can’t move in certain ways and has adjusted how she stands, bends and approaches basic tasks. There are times when there is no comfortable position for sitting or lying down. Doctors tell her she will need surgery, but advise her to put it off for as long as possible — until the pain becomes unbearable. She has been told there is only a 40–60 percent chance of her condition improving after surgery.
“At 85 percent, I would probably do the surgery,” Hughes, 43, says, “but it doesn’t seem worth it at 40–60 percent.”
Hughes’ condition may be more severe, but two out of every three people you know will suffer from back pain sometime in their lives. The boomer athlete who’s worn out body parts, the young adult with early onset arthritis and the soccer mom who bent over to pick up a towel and moved the wrong way — all are candidates for excruciating back pain.
More than 18 million Americans go to the doctor with back pain symptoms each year, and back pain costs businesses more in lost productivity than any other health issue.
When it comes to back pain, “There is no quick fix,” says Jean-Christophe Leveque M.D., assistant director of Group Health Physicians and Virginia Mason Medical Center’s Complex Spine Program. Most of the time when Leveque sees a patient with back pain, he does not recommend surgery. Most of his patients come in having experienced sudden pain, when last week everything was fine.
“It’s all about managing expectations and advising patients to give it time,” Leveque says. “Surgery may be helpful in certain conditions, but acute back pain usually resolves in a few weeks with less invasive treatments, such as rest, physical therapy, massage or spinal injections of steroids along the nerve.” Unfortunately, according to Leveque, we live in a culture that demands instant answers and immediate results. Some patients do physical therapy for one week or undergo one injection, become impatient with the results and think surgery is the answer.
Surgery isn’t indicated in cases of general, nonspecific pain, which is what most of Leveque’s patients experience. But it may help in cases where the cause of the pain can be pinpointed, such as a pinched nerve or compressed disk.
“I tell patients they may do better with surgery in these cases, but it’s elective. Let’s try other, less invasive treatments first,” Leveque says, but “I insist on surgery when there is evidence of neurological compromise (nerve damage causing weakness or numbness). Pain is uncomfortable, but it is not life threatening. However, neurological damage due to an injury or condition causing spinal compression can result in permanent long-term damage, disability and even death.”
In the event of surgery, patients should anticipate a lengthy recovery. Patients undergoing outpatient surgery to fix a slipped disk or pinched nerve should expect to be off work for two weeks and allow six weeks for full recovery. Moderate surgery for something like a single fusion means patients won’t feel like themselves again for about three months, Leveque says. It takes about this long before patients wake up without immediately thinking about the surgery they had. If major surgery is performed to deal with complex issues, such as the correction of a severe spinal deformity, it will take about one year for a complete recovery.
When it comes to neurological compromise, complex surgery and a long recovery, Renton resident Scott Hinton, 39, a superintendent in charge of day-to-day operations for a national general contractor, is a reluctant expert.
Two years ago, Hinton noticed pain in his legs and some numbness after workouts at the gym. “I ignored it, as most guys would,” Hinton says. But the symptoms didn’t go away. At 6 feet 3 inches and 240 pounds, the physically active Hinton began to notice weakness on the right side of his body. He couldn’t do certain routine tasks. Running on the treadmill became impossible. He began to limit activities with his daughter, Harlow, then an exuberant 3-year old. One evening while on a walk downtown, his wife, Aleeta, noticed that he was dragging his foot as he walked, but Hinton himself didn’t realize this was happening.
Hinton was diagnosed by Jayashree Srinivasan, M.D., a neurosurgeon at Swedish Medical Center’s Spine Institute, as having a genetic spinal disorder in which the spinal cord is too large for the spinal column. He also had arthritis, and “There were bone spurs jabbing my spinal cord,” Hinton says. “She didn’t tell me what I wanted to hear; she gave me the cold, hard facts. I like it straight and to the point — good or bad.”
Hinton needed surgery — as soon as possible. But the outcome would be unpredictable. “Dr. Srinivasan told me that, in my case, a successful surgery is one in which the symptoms don’t get worse. They may not go away or even get better, but the important thing is, they don’t get worse. Well, my symptoms haven’t gone away completely, but they haven’t gotten worse,” Hinton says.
“I had a cervical fusion of the 4, 5 and 6 vertebra through a small incision (which is no longer visible) in the front of the neck [through the throat], bone compressing the spinal cord was removed, a titanium cage was installed around the spinal cord for stability, and bone marrow was removed from my hip and placed in my neck [to speed healing].” Hinton was released the next day. “Recovery was rough,” he says, “but Dr. Srinivasan explained everything and told me exactly what would happen.”
Hinton’s surgery illustrates the dramatic technological advances made in spine surgery over the last 10 years. “Compared to the techniques used then, it’s like we are not even talking about the same subject,” says Rajiv Sethi, M.D., chief of neurosurgery at Group Health Cooperative, health services researcher and clinical assistant professor at the University of Washington. “We are light-years ahead of where we were then,” he says. Sethi is internationally recognized for his expertise in spine surgery and was recently a keynote speaker at the annual conference of the Spine Society of Australia and Scoliosis Research Society worldwide course in Brisbane in April. A research paper by his team was just accepted for publication by the prestigious journal Spine Deformity.
According to Sethi, technical advances have transformed the field of back and neck surgery, especially the use of minimally invasive surgical techniques. Smaller incisions in minimally invasive surgery means less blood loss, less damage to the surrounding tissues and quicker recovery times. Planning tools such as computer modeling and advanced imaging with CT scans enable surgeons to measure angles and plan an operation in detail prior to surgery.
And extensive research now provides reliable indicators for the selection of the right patients for surgery, increasing positive outcomes.
Sethi is particularly passionate about choosing the right patients and planning in advance. He and his team have published groundbreaking research on the topic from data collected by Group Health Research Institute and others, based on their work at Group Health and at Virginia Mason Medical Center, where Sethi’s team performs the surgeries. “We use a multidisciplinary team consisting of neurologists, orthopedic surgeons, anesthesiologists, internists, physiatrists, psychiatrists, nurses, and others. Two or three months before surgery, we bring together all the disciplines to review the patient’s complex spinal condition and potential issues to determine if surgery is the right option. Surgery doesn’t occur without this review — or if issues that were identified are not resolved. Sometimes we need to review a case as many as two or three times over a six- to nine-month period before a final decision is made. Two attending physicians do the operation: An orthopedic surgeon corrects deformities, and a neurological surgeon corrects issues caused by spinal compression. This means a safer surgery done in a shorter amount of time.”
The team’s results are stunning: Complications after surgery have been reduced threefold, by more than 60 percent. Sethi’s Seattle spine team has shared its findings and approach in numerous papers and at conferences, and has published a detailed how-to manuscript for other organizations, including a map of the operating room. Organizations from San Diego and San Francisco to Seoul and Munich have adopted portions of the Seattle spine team’s approach.
Other organizations also work with new and emerging technologies. Valley Medical Center in Renton is one of the only hospitals in the Northwest currently performing the FDA-approved artificial disk replacement surgery and is one of the few hospitals in the Seattle area to offer cervical disk replacement as an alternative to spinal fusion; this replacement procedure preserves more motion in the neck area after surgery than fusion does.
Abhineet Chowdhary, M.D., is Overlake Medical Center’s program director of neurosurgery and neuro-interventional surgery, and says the latest techniques in spinal surgery are gentler, faster and more effective. Overlake recently acquired a high-tech microscope that enables doctors to see details more clearly, reducing the need for repeat operations, according to Chowdhary. He is also the principal investigator in a clinical trial at Overlake using the iFuse Implant System, a minimally invasive surgery to stabilize the sacroiliac joint, which connects the spine to the pelvis, using a tiny incision and titanium rods. Usually this surgery is performed with a large incision and a screw-and-rod system and has only a 40–50 percent success rate.
The new approach yields better long-term results, 86 percent or greater, and patients recover much faster.
These are the kind of developments that Michelle Hughes hopes will help her in the future. But as we went to press, Hughes reported that she was again rear-ended while stopped in traffic. She is experiencing more intense pain and is scheduled for an MRI. She’d still like to postpone surgery, if the pain is manageable and the delay doesn’t cause more nerve damage.
“Things are changing so fast,” Hughes says, “who knows what new surgical options might be available in the next few years.”