FAQ Category: General Spine

Automated or remote monitoring of patient responses during surgery is being used more and more now. With improved technology, more complex spinal surgeries are possible. Severe spinal deformities from scoliosis (curvature of the spine) can be corrected. Tumors wrapped around the spinal cord can now be removed without damage that would result in paralysis.

But your concerns are justified. Others have asked the same questions. Another area of concern has been the reading and interpretation of test results via internet connections. The technician isn’t in the operating room with the surgeon providing real-time (instant) feedback. He or she can’t see the patient and is often monitoring more than one person at a time. Is that safe? What if the internet connection fails or there is some computer glitch?

There are also automated monitoring systems that are not managed by a live person. Although these have been approved by the FDA, some experts question whether it is safe to apply electrical stimulation to the brain and trust a machine’s interpretation of it?

Can we afford to take chances with someone’s life or put them at risk of permanent paralysis and disability? These are the kinds of questions that must be considered when establishing a standard of care for everyone who is undergoing complex spinal surgery with neuromonitoring. And that’s why the American Society of Neurophysiological Monitoring recommends all monitoring be done by a trained and certified technical professional.

For complex spinal surgeries that could potentially damage the spinal cord, spinal nerve roots, or blood vessels to these areas, surgeons use intraoperative monitoring (IOM) devices. These tools make it possible to check the patient and make sure everything is alright and no neurologic damage has occurred.

Physicians aren’t the only ones who can monitor neurologic intraoperative devices with accuracy. Many nonphysician technicians and professionals have proven their skill, ability, and experience with neuromonitoring.

In fact, the whole field of neuromonitoring was pioneered by nonphysician clinical professionals. Not just anyone can do the job. They must have proof of training or certification as required by the American Board of Neurophysiologic Monitoring. And recertification is required every 10 years.

Right now, efforts are being made to develop what’s called a standard of care (SOC). Such guidelines would ensure that all patients undergoing complex spinal surgeries would be monitored and that the monitoring would be done in the best way possible for each patient.

One of the problems with defining a standard of care is that each patient is unique and each procedure has its own twists and turns. Added to that are the differences in training among surgical personnel and ways to monitor these devices. There are no standard to dictate what is “proper” training and monitoring. There also isn’t a standard for who is qualified to read and interpret the tests.

Research to show what works best will help guide the use of intraoperative monitoring. The goals are to improve patient care and reduce the number of complications and problems.

Your surgeon understands all the ins and outs and pros and cons of monitoring. Don’t hesitate to ask how this tool will be used during your procedure and who will be doing the monitoring.

Any type of surgery can be affected by a person’s lifestyle and habits. Being overweight, malnourished, or an alcoholic can impair healing and recovery. With spinal surgery, there are many potential risks just from the technical side of the surgery itself. Adding health issues and concerns increases the chances of negative outcomes.

Patient safety is always important. Preventing and reducing adverse events (AEs) is always at the top of every surgeon’s list of priorities. Adverse events are different from complications. Adverse events refer to any unexpected problems that occur.

Complications can be defined as adverse events that have a measurable or observable (negative) effect on patient results or outcomes. All that is to say, Yes the surgeon should be made aware of any concerns the family may have about the patient scheduled for corrective spinal surgery.

Every effort is made to assess patients for risk factors and to prevent such problems. Patients with heart problems, diabetes, obesity, and who smoke or abuse alcohol are the most likely to develop complications after any surgery including spinal corrective surgery.

The surgeon will be conducting a careful preoperative patient history and physical assessment. Questions to uncover the use (and abuse) of alcohol are standard but many patients deny this aspect of their lives. Your input could potentially save your mother from unnecessary complications.

Here’s what we found in answer to your question from a recent literature review. Surgeons from the Albany Medical College in New York collected data on complications during orthopedic surgery involving the spine. They specifically focused on problems that are unrelated to the surgeon’s technical skill.

Surgeons have found the ideal position for patients having spinal surgery that is done to correct spine deformities like scoliosis. Without knowing for sure, it sounds like that might be the type of procedure your friend had (based on your report of post-operative blindness).

The patient is placed prone (face down) with the head, neck, and hips supported in a neutral position. The bed is tilted to keep the head elevated slightly above the feet. The arms and legs are supported in a restful position without pressure on the joints.

Using this position has helped improve breathing, reduce pressure on the heart and lungs, lower pressure on the head and face, and decrease blood loss. Even with this good position, new problems such as blindness have cropped up. Pressure on the face and loss of blood supply over a long period of time can lead to this loss of vision.

Blindness is a fairly new complication probably from increased surgical time and more health problems in patients having surgery. The loss of vision can be permanent so preventing the problem is a high priority. As a result, different head support systems have been developed for use during spinal deformity corrective surgery. Special eye goggles have also been invented to help prevent this problem.

Even with these protective devices, surgeries can last many hours. Anything over six hours puts the patient at increased risk for loss of blood supply to the optic nerve (to the eye). This type of negative outcome is rare. It is understandable that blindness as a result of spine surgery seems like a stretch. Patients are warned ahead of time about this possible complication but may not take it seriously because it seems so far-fetched.

Patient safety is always a number one priority for surgeon, anesthesiologist, and all other operating room personnel. Everything possible is done to watch for any signs of patient compromise and take measures to prevent problems, especially something as serious as visual impairment. This may explain what happened to your friend but the full details may offer a more accurate description of what went wrong.

Schmorl’s nodes represent a herniation of the disc material into the adjacent endplate. These defects often occur when there is disc degeneration (tears in the disc or thinning of the disc with narrowing of the disc space).

The endplate is a thin layer of cartilage sandwiched between the disc and the vertebral bone above or below it. On imaging studies Schmorl’s nodes look like small hollowed areas. Despite many studies on disc herniations and Schmorl’s nodes, no one really knows for sure what causes the disc to fracture the endplate like this.

Perhaps there are nutritional reasons. Disc degeneration with age might come with a decrease in blood supply to the area and subsequent loss of nutrition to the disc and the endplates. Your suggestion that there might be a genetic link has also been studied and there is some evidence that heredity may be a contributing factor.

People with a spinal condition called Scheuermann’s disease often develop Schmorl’s nodes. Scheuremann’s has a genetic component. The spine starts to curve forward putting pressure on the front of the vertebral bodies. the thoracic spine (middle of the back) is affected with narrowing of the disc spaces and Schmorl’s nodes.

An orthopedic surgeon is the best one to put a finger on why all three of you have schmorl’s nodes and advise you what to do about it. Because it is linked with disc degeneration, early diagnosis and treatment are advised.

A question like this can help the physician understand patients’ hopes and beliefs. Patients used words like permanent disability, crippled, and not going to get better to describe their expectations may have a different outcome from those who say they expect to get 100 per cent better or have a cure soon.

If a patient tells their doctor that their pain is from overdoing it, that may be different than saying the back is going or it’s old age. By asking a question like this, it may help your specialist see what are some of your beliefs.

Word choices are important — both what your doctor tells you about your condition and what you tell your doctor you believe about your problem. Using words that focus on healing, repair, and recovery rather than focusing on degenerative aspects of the spine may actually foster a better outcome in the long-run.

There are lots of studies done on children and adolescents treated surgically for scoliosis. Reported results among adults are harder to come by. A recent prospective study from The Johns Hopkins University reported on information gathered and observed results as they treated and followed older adults having fusion surgery for scoliosis.

All of the patients were at least 40 years old. Most were women. None had a previous spinal fusion surgery. They all agreed to participate in the study for a minimum of two years to give an idea of final outcomes. Most were in good health but everyone had at least one other health problem such as high blood pressure, heart burn, osteoporosis, depression, anxiety, asthma, and so on.

The surgery consisted of fusing the spine at multiple levels (at least 10 levels up to as many as 20 segments). Some fusions went to the bottom of the lumbar spine (just above the sacrum) while others fused the last lumbar vertebrae to the sacrum.

Information gathered from the patients during that time included questions about general health and the presence of comorbidities (other problems). They also measured outcomes using patient level of satisfaction, function, need for additional (revision) surgery, and development of complications. Complications were divided into two groups: major (e.g., death, blood clots, fractures, deep wound infection) and minor (urinary tract infection, nerve palsy, lung or spleen puncture).

The fusion procedures were done with today’s new technology and improved techniques and fixation devices. Devices used to fix (fuse) the bones in place included transsacral bars, alar screws, and iliac screws. This is the third-generation of instrumentation techniques — meaning the third round of improvements in these devices.

Analysis of the results showed successful fusion rates but with a high rate of complications. Almost half (49 per cent) of the patients had at least one problem following surgery. Most of the complications were minor and occurred later after the patients went home. The more major complications presented early and required additional hospitalization. There were no deaths and no cases of permanent paralysis.

The majority of patients were very satisfied with their improved results and said they would have the surgery again if they had to do it over. In fact, patient satisfaction was equal among all patients regardless of whether or not they had complications. Both mental and physical health improved. Many of the patients were able to return to work after recovering.

Studies report that the natural history (what happens to a person with a condition like scoliosis over time) suggests that the deformity will continue to progress (get worse) without treatment. The spine will lose what flexibility it has. You are likely to experience pain and loss of function beyond what you have already described.

Reviewing 35 cases of adults who had fusion surgery for scoliosis later in life (between the ages of 40 and 66) showed the following conclusion. Today’s fixation devices and improved surgical techniques make spinal fusion for scoliosis in older adults not only possible but very beneficial.

The improvements in symptoms despite the loss of motion and possibility for post-operative complications is enough to satisfy the majority of patients. Patients report improvements in both mental and physical health after spinal fusion for scoliosis. Many are able to return to work after recovering.

There is one important factor to note: fusion to the sacrum comes with some additional limitations and restrictions. Patients should be prepared for that before surgery. The sacrum is included in the fusion process when the lumbar spine is just too unstable or too fragile to allow for movement at the last lumbar/first sacral (L5-S1) level.

Improvement without surgery isn’t likely though this is something you should discuss with your surgeon. If there’s time, bracing, exercising, and a combination of alternative approaches (acupuncture, osteopathy, electrical stimulation) can be applied with before and after X-rays taken to document any changes. Again, your surgeon will help you make a reasonable decision about this.

Every year, trauma takes the lives of 1000s of North Americans between the ages of five and 44. For those who are not killed but survive, spinal cord injury is a major problem. If the accident victim is lucky, there will be a trauma center nearby to address any spinal cord trauma and other injuries that occur at the same time. Even better is the presence of a spine trauma unit.

New studies addressing the optimal time for surgery are just coming out. Timing for surgery after spinal trauma is a very important topic as every hour can make a difference in the final outcomes.

From studies done so far, the current recommendations are for early surgery for patients with severe neurologic injury. For those who have mild neurologic symptoms, a wait-and-see approach is advised to give patients time to heal and recover on their own.

Early stabilization of the spine and decompression of the spinal cord has been shown to reduce hospital costs by decreasing length of hospital stay and fewer days on mechanical ventilation (machines keeping the patient alive by breathing for them).

There is more evidence than ever to show support for early rather than late stabilization and decompression. Some surgeons advocate surgical intervention even earlier — within 12 hours rather than the 24 hours previously debated.

The final decision depends on whether or not the patient is stable enough to even have surgery. Family members may give the nod to go ahead or wait but you won’t have to do this without the expertise and counsel of the trauma team.

Much has changed in our knowledge and understanding of spinal cord injuries and the best way to treat them. New technologies and improved surgical techniques have changed the way these injuries are handled. Understanding the role of antiinflammatories and steroid medications has improved results by limiting pressure on the cord. Patients experience less permanent neurologic damage when swelling around the cord can be minimized.

But for all the knowledge we have gained, there are still some big holes in evidence to guide management of these injuries. In particular, the best time to do surgery is a key area of debate. According to a recent survey completed by 77 neurosurgeons, there really isn’t agreement about the optimal management of acute spinal cord trauma.

There isn’t just one factor to consider when determining whether surgery should be done immediately (within 24 hours) or later after stabilizing the patient. There are safety issues for the patient, staffing issues (is a properly trained neurosurgeon available?), cost analysis, possible complications to consider, and considerations centered on patient quality of life. And the level of the injury can make a difference, too.

There is some evidence that the longer the spinal cord is compressed (crushed, pinched, pressed by the damaged vertebrae), the worse the results. It makes sense to get the pressure off the cord as soon as possible.

But there can be other life-threatening issues that must be taken care of first. And there’s some question about what to do when surgery could make matters worse or even prevent the patient from recovering naturally. In cases where the cord is severed all the way across, the value of immediate surgery is less well-known.

You can be sure that the team of medical personnel who are working with your son are making every effort to determine the best course of action. This is obvious since they haven’t just launched into surgery without much discussion and consideration. It’s likely there are other variables at play in the decision-making process.

There are many different ways to measure pain. The simplest is asking a scale from zero (no pain) to 10 (worst pain) and ask the patient to give an objective (measurable) number to their subjective pain. This type of scale is called a numerical rating scale (NRS) or verbal rating scale (VRS).

Another example of a verbal rating scale is the Likert-type scale. This is one of the scales your physician is using. You pinpoint the pain intensity or severity using word descriptors such as no pain, mild pain, moderate pain, severe pain, or very severe pain. Each of these pain categories is divided into five separate levels of pain with equal distance between each pain item on the scale.

Another type of pain rating scale is the Visual Analog Scale (VAS). The VAS is made up of a straight line drawn on paper. The line can be drawn up and down (vertical) for patients who can’t sit up or straight across (horizontal) for those who can be seated. In either case, the line is always 100 mm long (about four inches).

For a horizontal line (straight across), the left end represents “no pain” and the right end represents “pain as bad as it could possibly be” or “worst possible pain.” When the line is presented in a vertical orientation (up and down) for the client who is lying in bed and cannot sit up for the assessment, “no pain” is placed at the bottom and “worst pain” is put at the top.

Any of these rating scales can be used to assess current pain, worst pain in the preceding 24 hours, least pain in the past 24 hours, or any combination the clinician finds useful. Both the Visual Analog Scale (VAS) and the Five-Item Verbal Rating Scale (VRS) have been tested and shown to be reliable and valid. In other words, each time the VAS or the VRS scale is used by itself, it really does measure pain in the same way from patient to patient and from one time period to another for each individual patient.

Many health care professionals use these two tests interchangeably as if they measure exactly the same thing. We know from other studies that the two tests are highly correlated. That means if someone has a high (or low) pain score on one test, they will also have a high (or low) score when given the other test.

But a recent study showed that the data collected from one test really isn’t the same as the other. Basically, what this means is that using five-items on the Verbal Rating Scale (none to very severe) isn’t the same as marking the 100 mm Visual Analog Scale (VAS) into five equidistant values.

A VAS between zero and three doesn’t really mean the patient’s pain level is “mild” as measured by the same distance on the Verbal Rating Scale. A VAS between three and six doesn’t correlate to “moderate pain” on the VRS. And more than seven (severe pain) on the VAS doesn’t match up with the higher categories of the VRS.

There is too much overlap of scores from one tool to the other to use them interchangeably as if they are measuring exactly the same pain levels. That could be why your physician is having you complete both forms — to give as much useful information each week that can be compared from week to week.

Complications of surgery can be a serious thing. Many people preparing for surgery are nervous and don’t always process what they are being told. Having a friend or family member present during the preoperative instructions is always a good idea.

In the case of a spinal surgery, the anatomy is complex and the risk of complications such as a dural tear are increased. Problems with spinal surgery are common even for the most experienced surgeons.

The dura is a protective lining around the spinal cord and brain. It has three layers to help provide a thin but strong structure. It provides an airtight, leak proof outer layer to contain the cerebrospinal fluid (CSF). The CSF cushions and bathes the brain and spinal cord in a protective plasma fluid.

Any time surgery is done on the spine, there is a risk that the dura will get torn or damaged. And if all three layers are torn, then the cerebrospinal fluid can leak out. If that happens, watch out! Major headache, nausea, and light sensitivity can develop after surgery.

Because dural tears are common during spinal surgery, the surgeon usually makes sure the patient understands the risk and the side effects of this complication. Patients are fully informed up front (before surgery) about the risk of a dural tear and the fact that if a dural tear occurs, a second surgery to repair the tear may be needed.

Surgeons do everything they can to prevent any and all complications. For example, they assess the patient ahead of time for risk factors that might help them prevent dural tears from occurring. Patients who understand the potential problems are better able to deal with them should they occur.

The lining you are referring to is probably the dura mater or dura for short. This is one of the many layers that help protect the brain and spinal cord. The dura also helps provide a tight seal for the cerebrospinal fluid (CSF) that cushions and bathes the brain and spinal cord.

Once the repair or reconstruction has been done the patient must rest. The goal is to reduce pressure against the repair site until healing has gotten a good foothold. For tears in the cervical spine, sitting upright reduces fluid pressure. For the lumbar spine, lying flat is best. It sounds like your wife might be having a lumbar dural repair since she will have to lie still after surgery.

How long does the patient have to stay in the prescribed position? Well, that’s a matter of debate. The old standard was 10 days — until healing took place. Gradually, that has been reduced with the use of medications to one to three days.

But more recent studies have even looked at no bed rest as a possible option with some good results. The surgeon will decide the optimal time for bed rest based on the size and location of the tear as well as the type of surgery done. That’s probably why you haven’t been given an exact time frame. Once the repair has been done, then the surgeon can decide more exactly just what the patient needs.

Be aware that even with a dural repair, the problem can come back. In fact, studies show that five to 10 per cent of all patients who have a dural repair procedure will spring a leak again. The main reason for this is that cerebrospinal fluid can leak out of the suture holes made to thread the stitches through the tissue. Efforts are being made to come up with alternate ways to repair the tear without using sutures.

You will be given instructions including what to watch for that might suggest a leak — headache, nausea, sensitivity to light — and what to do if that happens.

Over the years, doctors and researchers have tried nonsurgical methods of removing or relieving synovial cysts, fluid-filled masses that develop on the lining of a joint. Unfortunately, no method has been found to be very effective, so surgery becomes the default treatment if the cysts are causing considerable pain or disability.

Disc degeneration is a common cause of chronic low back pain. Most people recover from back pain with a little time and attention. Those who don’t are often treated with medications such as pain relievers or antiinflammatories. Some seek the help of a chiropractor, physical therapist, acupuncturist, or massage therapist. If the symptoms haven’t gone away after three months, the condition is becoming chronic.

But the pain can become so constant and intense that surgery to remove the disc and fuse the spine at that level becomes necessary. Can you wait too long to have spinal fusion surgery? Some research has shown that waiting too long may mean a poor result — the patient doesn’t get the pain relief hoped for. But how long is too long?

A recent study from Great Britain followed over 200 patients with degenerative disc disease to see how well they did based on how long they had symptoms before surgery was done. Some had back pain as long, if not longer, than you. Everyone included had at least two years of pain and had tried at least six months of conservative (nonoperative) care. But in the end, they all had discectomy (disc removal) and spinal fusion.

The results were very encouraging. Everyone got better. And the improvements (pain relief and improved function) stayed. The idea that a long period of pain leads to a poor prognosis wasn’t supported by the results of this study at least. Even taking into consideration factors like mental health (depression, anxiety) and general health (presence of other diseases or conditions) didn’t change the fact that the majority of these patients got better after surgery.

There is good reason to believe that if disc degeneration is the only problem you suffer and you don’t have other serious problems contributing to the pain (like fibromyalgia or arthritis), it’s not too late for that operation you’ve put off for so long. You’ll have a better idea what is possible and what to expect once you see your surgeon who will re-evaluate and advise you.

Inserting a needle into the damaged disc before removing it is called needle localization. It is a technique used by some surgeons who are preparing to perform an anterior cervical discectomy and fusion (ACDF). The procedure is used to confirm the correct operative level.

This method of checking works fine so long as the needle goes in the correct disc (the one that’s going to be removed anyway). But when the needle punctures a healthy disc at the next level (above or below the diseased disc), then that healthy disc is at risk for degenerative changes.

According to studies done, the practice of missing the correct disc space is more common than realized. Seventeen per cent (17%) of cases investigated had incorrect needle placement. And the risk of degeneration was three times higher for those previously intact discs.

More studies are needed but for now, there is a weak recommendation that surgeons should avoid using the needle placement checking technique to confirm the disc space for anterior cervical discectomies. Surgeons need to find other less risky ways to mark the appropriate disc space. The current needle localization method is linked with too many puncture injuries of the adjacent discs.

What you are asking for is a cost versus benefit analysis of a vertebroplasty for your father. That is a very reasonable request and one that you can ask the surgeon to help you with. What we can tell you from the evidence presented in studies so far is that for patients with painful vertebral compression fractures caused by osteoporosis, there is no long-term advantage of having a vertebroplasty procedure over conservative (nonoperative) care.

The vertebroplasty involves placing a needle into the fractured vertebra and injecting cement into it to stabilize the bone and keep it from further damage. When patients were treated with vertebroplasty and compared to those treated conservatively, the pain levels, level of function, and/or disability between the two groups was the same three months later.

However, the vertebroplasty procedure does offer faster pain relief in the early days of the fracture. That could be an important deciding factor for some patients. Some patients, families, and surgeons together decide to try the conservative approach for at least six weeks and see how much improvement occurs. If there is fair-to-good (or better) improvement, then the nonoperative treatment can be extended for as much as six-months before considering something else.

Anyone engaged in long periods of sitting is routinely advised to stand up and stretch periodically, shift weight in the chair at least once every hour, and engage in physical activity and exercise during the off-hours. But patient education of this type isn’t really based on evidence that doing these things reduces episodes of back pain or offers preventive measures against back pain. However, until more is known about the risks of occupational-related back pain, workers who sit for prolonged periods of time are still advised to follow these steps to assure good spinal and overall health.

It might be helpful to set a timer to go off every 30 minutes. Make yourself stop whatever you are doing, stand up and do at least one of the items suggested. Even if you don’t stand up, you can raise your arms overhead, take in a deep breath and then go back to your computer activities.

It’s also a good idea to establish some form of routine (daily) activity and exercise. Join a fitness club, biking group, take tennis lessons — something that has a set time for a daily regimen of exercise. This will benefit your body, mind, and back! It will enhance your overall health as well as stimulate muscle activity to restore blood flow to the spine, arms, and legs.

It’s important to keep a balance in life — even your life on the Internet. The fact that you are aware that it has become an addiction and you are seeking some way to protect your back is a good start.

Eating healthy, organic whole grain foods, fruits, and vegetables is always a good idea. Studies show that good nutrition is essential for maintaining good health, as well as healing quickly during recovery after events such as trauma (including surgery).

X-rays during spinal surgery are a must in making sure the surgeon is operating on the correct spinal level and making sure everything is lined up properly. In the case of using fixation devices such as metal plates, rods, and screws, proper placement can make the difference between success and failure. Screws can be placed in the wrong place or at an incorrect angle. An X-ray will show this during the procedure so it can be corrected right away rather than finding out later requiring a second surgery.

Every effort is made to prevent problems or complications from developing and X-rays help with that as well. The fact that your surgeon wants to use X-rays during and after the procedure is a sign that you are in good hands. Of course, let your surgeon know your concerns about over exposure to radiation. Physicians are well aware of the potential hazards of accumulated doses of radiation and do not expose patients unnecessarily.

Vertebral compression fracture refers to a mini-collapse of a vertebra in the spine. Tiny fracture lines in the bone (usually the front half of the vertebra) result in the bone taking on a wedge- or pie shape when viewed on X-rays from the side.

This type of fracture is most common in older adults who have osteoporosis (decreased bone mass or brittle bones). Just the weight of the body and pressure from postural changes (stooped head and shoulders) can put enough pressure (or compression, hence the name compression fracture) on the bone to cause a collapse.

Prognosis (how well the patient will do) depends on a number of things such as how severe is the fracture and how much of the bone is involved. Certainly, the degree of osteoporosis will make a difference in bone healing and recovery. The fracture itself is a determining factor.

The doctor will look at imaging studies (X-rays, MRIs, CT scans) to see if the fracture is stable (bone is broken but the broken pieces haven’t shifted or moved apart). More severe fractures with distraction of the fracture (broken pieces have moved apart) may require more extensive surgery using bone graft, plates, and/or screws to hold everything together while it heals.

A distracted fracture with jagged edges increases the risk for nerve damage. A partially or fully torn ligament puts the patient at risk for instability. Either of these conditions can lead to further problems if not treated quickly and effectively. Other prognostic factors include age, general health, and the presence of other problems such as diabetes, heart disease, cancer, and so on.