THE SPINE DIVINE

The spine demands delicate care when it's injured, misshapen or even fatigued from a lifetime of hard work.

by Christopher Tedeschi

 

Orthopedic surgeons concern themselves with the mechanics of the body, the physics of bone and motion. Neurosurgeons explore the intricacies of the nervous system, the body's complex wiring and the mysteries of the brain. Yet surgeons from these two disciplines meet at the spine, where bones and nerves are inseparably entwined.

Acting as both the body's central support structure and main electrical conduit, the spine demands delicate care when it's injured, misshapen or even fatigued from a lifetime of hard work. The Orthopaedic Spine Center at USC University Hospital has fast become a place to find the expertise needed to care for and revamp an aching backbone.

Shock Absorbers
One of the most common spine problems involves not the bones of the spine, but the small cushions between those bones. The cushions, called discs, help to reduce strain and friction over a huge range of motion.

Imagine discs as miniature shock absorbers between the vertebrae that make up the backbone. One disc between each pair of vertebrae helps to pad continuous bending, stretching, lifting and every other job that we ask our spines to perform.

But after years of use, some discs break down. They can even rupture, leading to the chronic pain of a ruptured disc. A "slipped" disc usually refers to a disc that is weak or torn open.

Ruptured discs often develop in middle age, after years of wear and tear. Heavy lifting, stress or injury can boost the risk. Yet any damage at all can cause the disc to weaken, and in an area with a poor blood supply, healing comes slowly, if at all.

"The inside of the disc is the consistency of rice pudding, while the outer layer resembles gristle," says William Mouradian, M.D., associate professor of orthopedic surgery at the USC School of Medicine.

When some of that inner substance breaks through a torn or weakened disc wall, it can press against a nerve in the nearby spinal cord, causing chronic and often debilitating pain.

"About 80 percent of herniated discs resolve without surgery, and most resolve spontaneously," says Mouradian, who prefers a conservative approach to treating disc pain. "We adopt a wait-and-see attitude, and the patient usually selects a surgical procedure only when other options haven't worked out."

Medical treatment and physical conditioning can help people with ruptured discs feel a lot better about their backs. Bed rest is almost never part of a treatment program, but instead Mouradian recommends reducing activity to a sensible level.

Since a good deal of the pain caused by herniated discs is caused by inflammation, Mouradian also uses analgesics and anti-inflammatory drugs in patients who feel no relief after modifying their activities. A course of steroid tablets or epidural steroid injections over a week or so is often used to reduce inflammation, and can provide relief for anywhere from a few days to indefinitely.

Rest, conditioning and medication can reduce the pain. Yet for some, surgery is required to remove damaged disc material.

Mouradian performs a procedure called a microdiscectomy by approaching the spine through an area smaller than the size of a dime. High-powered microscopes help him to remove material from a ruptured disc through this approach, which requires an incision about an inch and a half long.

Removing material that presses against a nerve can often have dramatic results. "There's a tendency toward making the procedure less and less invasive, and the only question most patients have is why they didn't do it sooner," Mouradian says.

After the damaged parts are removed, scar tissue develops in its place. It is important to understand that most of the disc remains in place. The disc won't behave exactly the same way after healing, but the cushion remains in place to lend support to the spine.

Bionic Backbones
Patients who need surgery to remove tissue damaged by cancer or other diseases often benefit from the support of rods and plates, carefully implanted to restore the spine's structural integrity. Mouradian relies on a new generation of titanium implants designed to support damaged spines.
For people who need to have two or more of their vertebrae fused together to eliminate pain, deformity or instability, surgeons use implants along the side of the spine to hold it in place and encourage bone growth. In order to provide a framework to which new bone cells can attach themselves, the area is seeded with the patient's own bone, transplanted from another area of the body.

A new graft material has recently shown promise. "If you need a fusion, coral works as a good substitute for bone," says Mouradian. The porous coral provides a hospitable environment for growing bone cells, which eventually give strength to the area of the fused vertebrae.

For the last two years or so, spine surgeons have been using titanium "cages" to support injured or deteriorating spines. A cage can replace a vertebral bodyall or part of a vertebraethat is removed or hollowed-out due to disease, trauma or tumor growth. The permanent implants work alongside metal plates and rods to lend support to patients whose own vertebrae no longer do the job.

Says Mouradian, "Recent research has resulted in many new implants for spine surgery such as the cages and also spacers that are used when a vertebral body is destroyed."

Exercise, Education and Patience

The potential for healing and increased quality of life that comes with surgery for both disc herniations and more serious conditions can only be tapped with proper conditioning and follow-up after an operation. At that stage, the guidance of a physical therapist means all the difference.

Wendy Burke, PT, OCS, assistant director of the Physical Therapy Department at USC University Hospital and instructor of clinical physical therapy in the Department of Biokinesiology and Physical Therapy, helps patients to minimize pain and maximize strength both before and after surgery.

After examining how a patient moves and rests, and after determining muscle strength and joint flexibility, she plans a way for each spine patient to accomplish their own particular goals.
"Patients learn how to sleep, move and work in the best range for their joints," explains Burke. "When a person learns how to be as nice as they can to their body, they can take the pressures off their spine and allow it to heal."

Long-term healing comes with exercise, patience and lots of education, regardless of the injury's severity.

"You have to be aware of certain precautions and the type of surgery performed. When a patient has fusions or rods that prevent spine joints from moving, they need to learn to move their body at joints above or below that point," says Burke. "My goal is to help them to do what they were doing before."


Doing It Right the First Time

Gordon Engler, M.D., professor of orthopedic surgery and one of the Spine Center's newest members, concentrates on severe deformities of the spine, many of which are caused by scoliosis or traumatic injury.

After spending 33 years at the scoliosis clinic and regional spinal cord injury center at New York University-Bellevue Medical Center, Engler hopes to build a similar center at USC.

"We're developing a center for both acute and long-term untreated spinal deformities," explains Engler. "A regional spinal cord injury center would handle patients from the surrounding area who have suffered spinal fractures."

With the budding collaboration between the USC departments of orthopaedic surgery and neurological surgery, along with Engler's recent addition to the faculty, the center is a valuable resource for health care facilities throughout Southern California.

To combine the strengths of orthopedic surgeons and neurosurgeons, Engler has teamed up with Srinath Samudrala, M.D., assistant professor of neurological surgery. Together, the two serve as co-directors of the spine-trauma service at LAC+USC Medical Center.

As a neurosurgeon who specializes in the spine, Samudrala is able to reconstruct the spinal canal, the long passage that jackets the delicate spinal cord, so that patients with injuries, or obstructions such as tumors, can have the best possible use of their nervous systems.

"We have the interest, the resources and the commitment to deal with every traumatic injury to every spine," says Samudrala.

Treatment at the center can be for injuries as soon as they occur, or for old injuries that have not healed well. For patients with damaged vertebrae and spinal cords, the best treatment is to receive the correct treatment the first time. But many spine-injury patients end up having second or even third surgeries for back injuries that weren't completely treated when they occurred.

Prolonged treatment means psychological stress, pain and lost time at work. "The individual, social and economic costs of not providing the best care possible the first time around are catastrophic," Samudrala says. "There are people facing the possibility of paralysis for the rest of their lives."

Many injuries show their effects years after they happen, though, when fractured bones in the spine fail to heal completely, or heal in a bad position. Those patients can still be treated, Engler advises, with a regimen of exercise and conditioning. And surgery remains an option for old injuries that need more dramatic correction.

Straightening a Curve

Some spine problems are caused by scoliosis. Many adults, explains Engler, find that scoliosis worsens with age or with increased stress on the spine. A regimen of good exercise and careful attention can lessen the pain that comes with the condition.

Almost always developed between ages 10 and 14, scoliosis is a curvature of the spine, which often causes the rib cage to tilt to one side. The causes of most scoliosis cases are unknown, Engler says. The disease can range from a barely noticeable curvature of a few degrees to severe malformations that need to be surgically corrected.

"We're finding more scoliosis cases early thanks to screening in schools, but some adults need treatment for scoliosis after the disease has progressed for many years," he explains.
While back braces often help to correct spinal curvature in children, Engler says, they are not typically used in adults. Instead, he advocates a conditioning regimen including physical therapy, swimming and low stress. While exercise can't straighten out a crooked spine, it can keep symptoms from getting worse.

In some adult scoliosis cases, surgery can correct a severe curvature. The scoliosis procedure is a major operation in which metal rods are implanted in a patient's back in order to straighten a curved spine. Additionally, surgeons fuse the vertebrae over the segment involved in the deformity.

"We decide to surgically correct scoliosis when the curvature of the spine is severe, and when we know that we can prevent further progression," says Engler. Surgery is usually an option when a patient's spinal defects are worsening, not when they remain at a constant level.

Regardless of the trouble, from a slipped disc to a serious accident, the Spine Center's orthopedic surgeons, neurosurgeons and therapists are helping more patients effectively deal with backbone illness and injury, encouraging them to keep their spines in line.

More information about the Orthopaedic Spine Center may be obtained by calling 1-800-USC-CARE.

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