Back Talk

By recycling their own blood during surgery, patients reduce the chance of transfusion errors as well as their reliance on a dwindling blood supply.

by Alicia Di Rado

Stand up straight!”

It may be the long-standing order barked out by the well-meaning mothers of slouching teen-agers—but it is a little off the mark.

While human beings stand and walk upright, their backs are hardly straight. And that is a good thing.

The very curves of the spine—the gentle slope inward below the waist, outward to the powerful shoulders and inward again to the nape of the neck—are what give the back its quiet strength.
With every hop, glide or reach, the spine acts like a spring. Its S-shape can squash and stretch, allowing the body to absorb impact while bearing the burden of its weight. Its flexibility allows the body to bend over to pick a flower, or to twist from side to side to swing an axe. And its rigidity, too, keeps the body upright.

Ah, but there is a catch. As elegant as this system is, it is also vulnerable: Serious problems can arise within the soft parts of the spine.

Vertebral discs—the spongy cushions sandwiched between vertebrae, which allow the spine to flex—may deform due to trauma. And over a lifetime, discs can suffer from wear and tear. Either way, it means pain.

Sometimes taking anti-inflammatory pills or lying down helps. But when rest cannot ease the hurt,today’s physicians have more ways than ever to put patients’ back pain behind them.

“There are so many new tools that are becoming available to us,” says spine surgeon Mark J. Spoonamore, M.D., assistant professor of orthopaedic surgery at the Keck School of Medicine of USC and director of the USC Center for Orthopaedic Spinal Surgery at USC University Hospital.

According to physicians, the next decade will revolutionize the way doctors treat back pain. Says Michael Wang, M.D., assistant professor of neurological surgery: “Minimally invasive surgery, bioengineering, non-surgical treatments, even genetic engineering to recreate the body’s own tissue—it’s all here or it’s on the horizon.”

Rest first, cut later

For those coping with agonizing back pain, it may be a surprise that many back problems can be solved without going under the knife.

“I try to talk patients out of surgery,” Wang says. “I say that because I have to have very strong, convincing reasons for a patient to undergo a procedure.”

Wang’s colleague Srinath Samudrala, M.D., director of the USC Neurological Spine Surgery program, says the program’s new Complex Spine Clinic aims to use non-operative techniques in a majority of cases. “Once you’ve done an operation, you’ve done it,” Samudrala says. “It’s best to try other strategies first, and if they fail, then surgery is an option.”

The once-a-week Spine Clinic features three spine surgeons, as well as pain-management physicians, radiologists and physical therapists.

Doctors start by suggesting conservative treatments: physical therapy, exercise, rest, muscle relaxants, non-steroidal anti-inflammatory drugs (including ibuprofen or naproxen) and analgesics such as acetaminophen. Some physicians also try injections of cortisone to reduce inflammation.

Experts estimate that four out of five patients with a herniated or ruptured disc, one of the most common injuries to the spine, improve without surgery. If patients still hurt after six months to two years of conservative therapy, they may start considering surgery.

For some, that sets off alarms. Back surgery, after all, is not something to be taken lightly.
“Half the people coming into my office say ‘I know someone who had that disc surgery years ago, and he’s still hurting,’” says Samudrala. But unlike back surgery techniques of the past, many procedures are now done with smaller incisions, less trauma and a speedier recovery time.

Take the microdiscectomy, for example.

When a herniated disc bulges out of its space and pinches a nerve, surgeons may be able to ease pain by removing part of the disc material and decompressing the nerve through microdiscectomy. “If there’s a large disc fragment, we can make a single poke hole in the back. Using a operating microscope, we can trim away that tissue—all through this tiny hole,” Spoonamore says.

Surgeons are even combining these minimally invasive techniques with new forms of disc treatment that are still under development.

Wang, for one, performs a nucleoplasty, which uses heat to relieve bulging discs and takes the pressure off compressed nerves.

“We actually ‘burn’ the disc,” Wang says. “It’s a good first step. It gives about 70 percent success, and if it helps, it can last five to 10 years. If it doesn’t, the patient can still undergo a different surgical treatment.”

For a nucleoplasty, the surgeon inserts a probe through the back and into the disc. The probe emits radiofrequency waves, which break up some molecules of the gel in the disk nucleus and take the pressure off the disc.

In another similar technique, the surgeon inserts a hollow needle, instead of a probe, into the annulus, the rigid ring that forms the outside of the disk. A heating wire delivered through the needle then curls through the annulus. The wire heats for about 15 minutes, seeking to firm up the annulus’s collagen fibers, stunt tiny pain receptors and seal tears. Sporting just a small bandage on the skin and a brace to stabilize the back during healing, the patient can usually go home that day.

Surgeons and researchers also are investigating other options. They are investigating the use of tiny pillows or spiral, coiled loops of synthetic gel to replace the nucleus, for example. Bioengineers also are trying to grow the body’s own disc cells in a collagen matrix, hoping to use the new cells to replaced damaged ones.

USC biomedical engineer and surgeon Charles Y. Liu, M.D., Ph.D., assistant professor of neurological surgery, is taking it a step further, studying the possibility of turning stem cells into replacement cells for the spine.

Sometimes, though, the strategy with the best chance of easing a patient’s pain is to remove the disc altogether. Even then, patients have increasing options.

Disc-o-tech

Mention back surgery, and the procedure most likely to come to mind is fusion, in which surgeons remove one or more discs and then fuse the surrounding vertebrae together.

Surgeons today perform a variety of fusions depending on the patient’s needs. Whether they approach the spine through incisions in the abdomen, punctures in the back, or both, the basics are the same:

They must encourage the vertebral bones to grow together, and they must somehow keep bones still while they heal.

Bits of bone have traditionally been used as a sort of mortar to bridge vertebrae together. Surgeons may use grafts of a patient’s own pelvic bone or processed bone from a deceased donor. They may even use bioresorbable materials—substances that gradually break down and are absorbed into the body—or artificial materials, all infused with substances that encourage a patient’s own bone tissue to connect the vertebrae.

“We also can aspirate bone marrow from a patient, and then use that bone marrow to create new bone from that patient within a sort of structure or scaffold,” explains Wang.

At the same time, they fixate vertebrae by inserting screws into the bones and then connecting the screws with metal rods, or inserting a cage between vertebrae. In the past, such procedures could cause significant trauma to surrounding tissues. But today, surgeons have new, minimally invasive tools they hope will cause less scarring and reduce recovery time.

Experts such as George P. Teitelbaum, M.D., and Donald W. Larsen, M.D., neurointerventional radiologists at the Keck School and USC University Hospital, employ some of these new tools.

Teitelbaum, for one, invented a unique way to fixate two or more vertebrae through a few punctures in the skin. Under his system, he first inserts an expandable catheter through the back. After placing the screws in the vertebrae, he runs a guidewire through the screws, and then runs an expandable sheath over the guidewire and through the screws. A special composite fluid is injected into the sheath, filling it and giving it shape. In less than an hour, the fluid hardens into a high-strength rod within the patient.

“This allows us to navigate complex pathways,” says Teitelbaum. “Extensive dissection is the main reason for failed back syndrome, denervation and necrosis after surgery. Minimally invasive surgery aims to be gentler.”

Back to the future

Some surgeons, though, are beginning to offer a viable alternative to fusion: an artificial disc to replace the body’s own degenerated discs.

So far, the United States Food and Drug Administration has approved only one such device, called the Charité disc, explains Spoonamore, though other devices are being tested.

Meant only for arthroplasty in the lower spine, the Charité disc and other similar products are “a very exciting concept,” says Spoonamore, who first used the investigational devices during his spine fellowship at Good Samaritan Hospital in Los Angeles. “They are usually entirely made of metal or are a metal-plastic-metal sandwich,” he explains.

When surgeons install these devices, they must shave away all traces of the patient’s own degenerated disc, then tap two metal endplates onto the flat sections of the surrounding vertebrae. In the case of the Charité disc, they place a slick polyethylene puck between the two metal endplates, allowing the joint to pivot.

Spoonamore and Thomas P. Hedman, Ph.D., Keck School assistant professor of research in orthopaedic surgery, have been studying the discs in the lab, analyzing their durability and how they affect the mechanical loads on other parts of the spine over time. “The artificial disc seems to reduce the stress on adjoining vertebrae that is associated with a fusion surgery,” Spoonamore says.

Surgeons in Europe have been installing artificial discs since the 1980s, but they are not a cure-all, he says. The discs are only appropriate for certain patients, and they must be implanted skillfully.
Just as in all back surgeries, patients might need to return for revision surgery; patients also need to know that the surgery might not completely resolve their pain. Each surgery carries risks, says Wang, and patients must keep that in mind.

But as researchers keep advancing toward less-invasive procedures and as engineers create new materials and devices that are increasingly readily accepted by the body, medicine will have a greater toolkit for trying to ease back pain.

“Within the next 10 to 20 years,” says Wang, “you’ll be amazed at what develops.”

For more information about back pain treatment, call 1-800-USC-CARE (1-800-872-2273).

 

back to basics

Adults have 24 vertebrae that run from the base of the skull to the tailbone. Not only does this series of vertebrae form the spine, but it also houses nerves that run down from the brain and branch out to the body.

Discs, meanwhile, form the supportive cushions between vertebrae.

Each disc consists of a soft, jelly-like core—called the nucleus pulposus—which is surrounded by the annulus fibrosus, a firm, protective hoop made up of layers, much like the rings of an onion.

Sometimes, the annulus weakens and cannot do its job of holding the nucleus inside. Under the pressure of the vertebrae that sandwich it, the nucleus pushes on the annulus, which may bulge outward. This is called a herniated, slipped or torn disc. In some cases, the annulus is so damaged that some of the nucleus leaks out of a side of the ring—like a squeezed jelly donut.

This can cause pain in the back itself, or if the bulging disc pinches or presses on a nerve in the spine, the pain may shoot to the area of the body that the nerve serves.
Most painful herniated discs happen in the discs of the lower back, called the lumbar region. Nerves that branch from the lumbar spine go to the legs, so pain in the legs—or sciatica—is a frequent complaint. Disc problems in the neck, or cervical region, may cause arm pain.

Not all disc problems come from accidents or trauma, though. Some of them just occur naturally over a lifetime.

As discs become more rigid and less elastic with age, their chemistry can change and the discs may gradually dry, shrinking the space between vertebrae and leading to arthritis, bone spurs and pinched nerves. This is called degenerative disc disease.

Disc degeneration does not necessarily mean pain, though. Many people show evidence of degenerative disc problems on imaging scans, but have no troubles with back pain at all.

 

back strain

When a sudden back sprain or strain hits, the pain may seem debilitating—but according to Mark J. Spoonamore, M.D., assistant professor of orthopaedic surgery at the Keck School of Medicine, most back strains are temporary and respond well with time.

“There is usually no need to get alarmed in the first few days of this sort of back problem,” says Spoonamore, who sees patients at the USC Center for Orthopaedic Spinal Surgery at USC University Hospital. “And it doesn’t mean you have to lie in bed for days.”

Back strains are the most common form of back injury, he says. Americans spend $50 million a year treating low back pain, the leading cause of days missed from work.
Outside of traumatic accidents, back pain most often comes from a strain in one of the many muscles or ligaments that help the back twist and turn.

Over-the-counter anti-inflammatory medications, such as ibuprofen or naproxen, can be taken every few hours as directed on the bottle to ease pain and inflammation. During the first few days of the injury, Spoonamore recommends putting a wrapped cold pack on the site of the pain and resting the back from further strain.

But resting for longer than two days is not a good idea, he notes. Back-strain sufferers should get back on their feet and gradually move around. They also may continue to apply ice to the site, though they may want to switch to applying heat instead, if that seems to help.

If strong pain persists for longer than two days, or is accompanied by bruising, leg pain, or weakness or tingling in the legs, Spoonamore suggests getting a doctor’s opinion to rule out a more serious problem.

He also suggests following well-known prevention tips such as bending at the knees when lifting heavy objects and stretching and warming up before strenuous movements or exercise.

The most important prevention advice, he says, is to follow a program of activities or exercises that strengthen the abdominal and trunk muscles, often called the core muscles, which provide support and balance to muscles of the back.

“Even serious athletes who work on their arm and leg strength can suddenly have back strains because their abdominal muscles are weak,” says Spoonamore, who specializes in complex spine disorders and has worked with high-performance athletes.

Spoonamore can refer patients to physical therapists who present back-pain sufferers with an appropriate series of core exercises that carefully build strength and flexibility. Patients often can perform these exercises at home, school or in the office.

At the USC University Hospital Center for Athletic Medicine, physical therapists help patients from young athletes to weekend warriors strengthen their core muscles through a specialized program, he says.

Adds Spoonamore: “It’s intense, but it works.”