Frequently Asked Questions:
Q: Does severe back pain mean that something is dramatically wrong?
A: While it might seem obvious to assume this, the severity of pain does not necessarily relate to the likelihood of having a serious condition requiring intensive treatment. Most cases of back and even leg pain resolve on their own. There are many instances where a patient can have symptoms suggesting a surgical problem, yet the studies will be normal. For this reason, except in certain circumstances, non-operative treatment is usually recommended first.
Q: I am having severe back and leg pain. Do I need an MRI?
A: Usually not right away. Even those patients with severe pain will often get better with non-operative treatment.
Patients of different age ranges and occupations have different considerations. It is not uncommon to get an X-ray on the first visit. An X-ray can be a useful screening tool for significant abnormalities, such as a fracture or tumor, but can be less useful for a strain type of pain. An MRI is usually ordered when there is more information needed to decide whether a more agressive treatment recommendation, such as injection or surgery, needs to be considered.
If a patient presents with symptoms including neurological problems such as weakness, paralysis or loss of bladder control, a full work up, including an x-ray as well and an MRI or myelogram will be ordered. Weakness or loss of control of bowel or bladder need to be taken very seriously and usually require immediate attention.
Q: I’ve been told I have a disc herniation. Is that the same as a slipped or ruptured disc?
A: Really these are both sides of the same coin, like the difference between Kleenex and tissues. The disc is the cushion between the vertebral bodies that separates them, bears the weight, and yet allows some motion to occur. The disc has a structure like a jelly donut. Although the center is not actually jelly-like, the analogy is still appropriate. A slipped disc or herniated disc describes a condition where some of the jelly has squirted through the dough and is touching the nerve. Whether you think of the dough as tearing or rupturing or slipping, the distinction is just a choice of words. The term refers to some type of disc problem.
Q: Do I need surgery if I have a herniated disc?
A: Again, it depends. In this regard, there is good news and bad news. The good news is that most cases do get better with non-operative treatment within 6 weeks. These conditions are generally not life threatening, and there is time to get a second opinion. The bad news, however, is that there are some cases where surgery is needed and further delay will not help, but rather can only worsen the final outcome. Anyone with a worsening set of symptoms, i.e. increasing pain, weakness, paralysis, loss of bladder or bowel control, poor coordination of the hands, or an unsteady gait, needs urgent, if not emergency, evaluation by a spine surgeon.
Q: What does conservative treatment mean?
A: Usually this term refers to any treatment that can help avoid surgery. Generally, we begin with medications and physical therapy including exercise. On occasion, we need to incorporate more aggressive interventions such as epidural injections. These techniques allow you to be more comfortable during the early phase of a painful spine problem. They are not curative, rather they are designed to give you relief while waiting for the symptoms to settle down. In the long run, a consistent, aerobic exercise program will help people decrease the frequency of the spine symptoms. In addition, it is important to understand the basic rules needed to protect your back while staying active. This may help prevent recurrences.
Q: How can I decide whether to have surgery? Since you’re the doctor, won’t you tell me?
A: Unless there is muscle weakness or loss of control of bowel or bladder, in most cases, the decision of whether to proceed with surgery is up to the patient. The decision can be based on whether you can tolerate the symptoms. Since surgery has some risks, there is no rush to decide. When you feel like you’ve tried everything else and you are chosing not to live in your current state of pain and discomfort, and assuming there is a surgical option, it is very reasonable to proceed with surgery. While the job of the doctor is to assess your situation, diagnose the cause of the pain, educate you about the pros and cons of surgery and the chances of success, the ultimate decision of whether to proceed is yours.
I recently added a video on this topic which can be seen by clicking here or by clicking on the video below.
Q: How will I know if I’m medically ready for surgery?
A: If you have any kind of medical problem for which you receive regular care, you will need a pre-op clearance from your doctor. If your doctor doesn’t go to the same hospital where I perform the surgery, we may need you to meet and establish a relationship with another doctor who does, so they can get to know you. That way, should an urgent situation arise (not planned, of course), you will receive care from a physician who is already familiar with your history and issues.
Q: What can I expect as my post op course after surgery?
A: It depends on what surgery you have and how much work is done. The answer for some common surgeries is listed below.
-Anterior Cervical Discectomy and Fusion: Usually stay one night in the hospital, with discharge being when pain controlled with pills and you can swallow. Some patients can go home the same day. Most patients have a sore throat for about a week. The soft collar should be worn mainly when out of bed for about a month. This collar serves as a reminder for the patient not to do too much, and for those around the patient to be careful.
-Microdiscectomy: Depending on pain level, may either be discharged same day, or stay one night in the hospital. Avoid bend, lift, and twist (BLT) for about a month.
-Lumbar Fusion, Minimally Invasive or Open: Usual hospital stay is 2 days. For open cases that require more time in the operating room, possibly longer. The first night after surgery, you will have a machine called PCA (stands for “patient controlled analgesia”) which allows you to push a button and have a dose of morphine or demerol delivered directly to you by IV. While the PCA is in place, a catheter (tube) will remain in your bladder to prevent urinary retention. Most patients are off of the PCA the first or second day, with injections as needed for severe pain. Many will be able to control pain with pills. Once off the PCA, the catheter can come out of the bladder. Usually, patients will wear a lumbar supportive brace for 6-8 weeks when walking. If sitting in a chair, a small pillow in the small of the back will suffice.
You can be discharged from the hospital when you can walk, urinate without problems, and control your pain with pills. Any equipment you may need for you to get along at home will be ordered for you, along with any home therapy.
The reason you wear the brace afterwards is to help maintain the curve in your lower back.
When you sit unsupported, the curve flattens out or reverses.
With a brace on, or a pillow in the small of your back, the curve of your lumbar spine is maintained.
Q: What else do I need to know after surgery?
Many other frequently asked questions and answers are listed here:
Wound care: The wounds are closed with absorbable sutures. There are no stitches to remove. Occasionally, there is some drainage from the wound. A clean gauze dressing is used to cover the wound as long as any drainage is occurring. Once there is no drainage, no dressing is needed. The wound may get wet with bathing, but until the first follow-up visit, avoid going in a bath or pool (standing water). When showering, a shower chair is helpful to decrease the chance that you might slip and fall.
Movement: Several guidelines work here. For one, avoid bending, lifting, and twisting (remember BLT). Also, if you imagine there is a cup balanced on the top of your head, by avoiding the types of body positions that would make this cup fall off, you will likely stay out of trouble (even though you will have to do these movements sometimes, like when getting dressed). Also, although common sense, avoid positions that cause pain.
Smoking: This activity can adversely affect your fusion. The amount of oxygen needed by the tissues for healing and fusing is 300% of the amount needed just to stay alive, and with each cigarette, the tissues that need the oxygen most are being deprived of this essential element. Additionally, nicotine can adversely affect healing.
Lifting: Probably best to avoid lifting more than about 5 lbs. for the first six weeks, and keep the item close to your body when lifting it.
Exercise: No restrictions on walking, stationary biking, or swimming (after wound heals) until advised otherwise by your physician.
Physical Therapy: Usually, a formal program is not started until it appears that the fusion is well on the way to fusing, at around the four month mark in most cases.
Nutrition: Since patients sometimes have a decrease in appetite in the first few days after surgery due to stress and pain, nutrition is sometimes a concern. The process of healing a significant surgical wound requires good nutrition, including adequate protein intake. While protein rich products (like meats, eggs, dairy products, fish) are important, it is also important to eat a balanced diet. A multivitamin with iron can usually suffice for other vitamin needs.
Driving: Patients are allowed to return to driving when they feel comfortable getting in and out of the vehicle, and sitting in the car, making the movements required to drive. These movements include steering, and moving the foot from the gas to the brake pedal in case a quick stop is required. For patients with neck surgery, they need to be able to comfortably see the other vehicles, which requires some degree of neck movement. Keep in mind, if there is an auto accident, the discomfort will increase significantly. Some patients can drive within a few weeks of surgery, and others take longer to feel comfortable.
Pain Medications: Certain medications, like anti-inflammatories (Advil, Motrin, Naprosyn) and oral steroids can affect the fusion adversely, and should be avoided for about six months after surgery. Narcotic pain medications are usually used to control the pain, but since they can be addictive, there is a focus on trying to get off these medicines at some point.
Metal Detectors: Most implants are made of titanium, and don’t set off metal detectors.
Fatigue: It is not uncommon for patients to feel fatigue, and even a mild depression, for upwards of roughly four months after a spinal fusion. These symptoms usually pass.
Q: If I have surgery, how long will I be out of work?
A: The answer also is, it depends. The time out of work is a factor of what kind of surgery you are having and what physical demands are placed on your body at work.
From a general standpoint, for any type of fusion surgery, where we are trying to get two or more bones to heal as one, the time until you’re released will be several months, at least three for sure. unless limited work is available where the surgery will not be stressed. When the surgery involves only decompressing nerves, such as with a herniated disc or narrowing around nerves (stenosis), often the recovery is quicker, with a recommendation to avoid bending, lifting, and twisting (think BLT) for approximately six weeks.
Clearly, the recommendations are individualized for each patient and work situation.
Q: Where do you get the bone you use for a bone graft?
Most bone is from the tissue bank. Bone, as with all other tissues used for human transplantation, are checked very carefully and cleansed thoroughly to avoid disease transmission or cause immune reaction. The bone usually comes from fairly healthy people who due to unfortunate circumstances became organ donors. Bone is harvested in these situations as well, and can be processed in a sterile manner to produce grafts for use in orthopaedic and spinal surgery. Although the option exists for patients to use their own bone from their iliac crest (pelvis bone), the site from which this bone is harvested often is more painful than the spinal surgery itself.
Q: I’m claustrophobic, but I heard your practice has an MRI. Can I see a picture of the scanner?
Q: I have heard about laser for spinal surgery. What are your thoughts?
A: First, I was at a meeting where a practice with “laser” in their name was discussing spinal treatments. I didn’t share that I am a doctor, but I asked the presenter what the laser has to do with the treatment. His answer was “it’s just part of our name.” Also, I found a web page here that reflects my thoughts on the issue also.
Q: I have heard about a Georgia Drug Card. Do you have any information?
A: Yes, I have recently (Sept ’13) learned about a program sponsored by pharmacy companies to provide discounts to the citizens of Georgia.
The Medical Association of Georgia has been working with a statewide prescription assistance program called the Georgia Drug Card since 2010. The Georgia Drug Card is free for all Georgia residents, and it can be used for savings of up to 75 percent on prescription drugs at most retail pharmacies. The Georgia Drug Card discounts non-covered medications, as well as medications for residents who don’t have prescription coverage. The program has no membership restrictions, no income requirements, no age limitations, and there are no applications to complete. The program is funded by pharmacy companies.
Patients can print a free Georgia Drug Card at http://www.georgiadrugcard.com/. They can also secure the discount by simply walking into any CVS/pharmacy in Georgia and asking for the Georgia Drug Card discount – even if they don’t have a physical card.
Patients can also click here for more information.
Q: Any videos on this site?