Back surgery, am I candidate?

Will back surgery alleviate back pain? Sarah Bush Lincoln Advanced Practice Provider Kayla Deters talks about what types of back pain can be helped with surgery and those that cannot.

Transcript

Unknown: 0:01

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Speaker 00: 0:02

Oh, my aching back. How many times have you heard that phrase, or maybe you've said it yourself? Is that pain in your back or neck something that requires surgery? You might be surprised by the answer. In this podcast, Kayla Daters, who is an advanced practice provider with Sarah Bush Lincoln Neurosurgery, will break it all down for us. She'll talk to us about disc herniation, degeneration, stenosis, fusion, as well as common myths and misconceptions .

Speaker 01: 0:47

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Speaker 00: 1:15

Welcome to Health Styles. I'm your host, Lori Banks. And today we're talking with Kayla Deters. She's an advanced practice provider at Sarah Bush Lincoln. Kayla, it's great to see you again. It's been a while.

Speaker 02: 1:25

Yes, it's so good to see you. Thank you for having me.

Speaker 00: 1:28

All right. Well, tell us a little bit about your practice and area of specialty.

Speaker 02: 1:33

Yeah, so I work in neurosurgery. I'm a nurse practitioner and I work under Dr. Nardone. So he's been with Sarah Bush for quite some time. He's also with Carle And he's also at the Bloomington office, but I strictly see patients with Sarah Bush. So I've been with him for... going on three years now, but I've been working in spine since 2018 here at Sarah Bush.

Speaker 00: 2:01

So what do you do in terms of seeing patients? Like how does that work?

Speaker 02: 2:06

So generally what my job consists of, I spend about half of my time in the clinic setting and I will work up new patients. So patients that maybe have never seen a back specialist before, maybe they've been seen a few years ago and they have a flare of pain, they're coming in for a follow-up post-ops that have had a recent surgery. So I spend a lot of the clinic time working up those types of patients or doing follow-ups. And the other half of the time I spend assisting Dr. Nardone in surgery.

Speaker 00: 2:38

Okay. And that's why we're talking to you today. Am I a candidate for back surgery? Because I know you talk to a lot of people who come in with back pain. And we're going to get into that in just a minute. But I wanted to ask you, what interests you about the spine? It's very complicated and lot going on there. What do you like about it?

Speaker 02: 2:56

So there's several things, but I would say probably the biggest thing is how relatable it is to patients. So majority of people will experience back pain at least once in their life. And so the fact that it is so common, that I have the ability to help people through that, whether they only experience it for a week, or it's something they lived with for years and years. I love to help people. So that's why The other is educating patients. I think everybody could benefit from education on their spine health because it is such an important part of our bodies and our mechanics. So educating patients is a passion of mine as well. And it's also rewarding to be able to see in the surgery setting patients that come in for a new visit. They have pathology that is treatable with surgery. We help them and to see them post-op so much better to be able to get back to their daily activities. So that's very rewarding. I really enjoy that aspect as well.

Speaker 00: 3:58

Right. Well, you, me, and probably everyone listening has had experience with back pain. So what are the most common sources of that pain?

Speaker 02: 4:07

So actually, the majority of the time, over 85% of the time, when someone experiences back pain, it's what we call nonspecific, meaning there's actually no underlying pathology. It's more of a musculoskeletal. Maybe you sprain the back. Maybe you over used. You sat too long. So majority of the time, that acute pain that you might feel after you sit in a car or something of that nature is actually self-limiting. So within a few weeks, it will most likely go away. So most of the time, it's more of that nonspecific. Less than 1% of the time, is it ever something very scary like cancer or something life-threatening. And then there's obviously the percentage of times when it is something underlying, like narrowing around the nerves, which we call spinal stenosis, maybe a disc herniation, maybe the result of some arthritis or degeneration. So those are more of the common aspects, but the majority are more musculoskeletal in nature.

Speaker 00: 5:10

All right. So I'm sure in your line of work, when people find out you deal with back pain and spine, you get all sorts of questions. But you probably get a lot of myths and misunderstandings from people about back surgery. What are are some of those

Speaker 02: 5:24

yes I have a big list of topics to discuss because there are many misconceptions or misunderstandings and probably the biggest one would be that if I have a back surgery I'll never have back pain again and there's many reasons why that's not the case you know surgery can definitely fix the main problem at hand but we have to think that the spine is many levels it's it's not one joint so when we're thinking of a back surgery, we generally will address the main area of concern, but there are other levels adjacent and throughout the remainder of the spine that can become problematic. So the goal of surgery is to fix the present problem and hope that nothing else arises, but it definitely can. The other is that Right after a surgery, you'll be pain-free. So the muscles, the nerves, they do take time to recover. So if someone has a big disc herniation, we do a surgery to free up that nerve, take the disc away. They might wake up and still have that irritation in the nerve. The nerve has to take time to heal, to recover. And a lot of people are shocked if they wake up still having the pain, but in time it usually gets better. Okay. So those are two of the more common ones. Another big misconception would be a herniated disc will always require a surgery. Actually, it's most common that they don't. So 90% of the time, a disc will actually resorb or shrink on its own. And the bigger the disc and the further it extracts, which we call an extrusion, away from the main portion of the disc, actually the higher rate that it will

Speaker 00: 7:13

shrink Exactly to me about 25 years ago was the extrusion. And I was like, I have to have surgery.

Speaker 02: 7:20

Yes. I did not need surgery. And it's very common that by the time a patient will... go to their primary doctor, maybe go to the ER, get medicine, give it a little time, eventually get in to see us. Majority of the time, they'll come in with me and say, the pain's gone. And I'm not shocked at all, but

Speaker 00: 7:39

they're shocked. So are slipped disc, herniated disc, disc bulging, that all the same thing?

Speaker 02: 7:45

So it's not. That's another misconception. So I like to describe it like a tire. So if you imagine a tire in a brand new car, it's full of air. and over time you drive that car you drive that car say you don't fill that tire up it's going to begin to lose air it's going to begin to kind of bulge if you will so that's more of the description for a bulge now a herniation is where a focal point in that circle or that tire pushes out or herniates through so there's two two layers of the disc there's the middle which is a jelly layer and then the outer layer which is a fibrous layer so the herniation would be where some of that jelly kind of pushes through the fibers. If you imagine a jelly donut. So some of the jelly squeezing out, that's more of a herniation versus the bulge is more circumferential. And, you know, a bulge is something actually that's very common. So a lot of patients will come in, maybe they've read their MRI reports, and they're very concerned. I was told I have a disc bulge. So a bulging disc actually is very common. you know majority of patients whether they have pain or not when you get to a certain age you're going to have a disc bulge show up on your imaging so that doesn't necessarily concern me if the bulge becomes big enough where it is causing nerve compression then obviously you begin to become symptomatic we can treat that but a bulge in general is not something that I'm overly concerned about if it's not causing any problems now a herniation dependent on where it is is If that focal piece of disc is pushing on a nerve, then you're symptomatic. That is something that, you know, we want to treat. So those are descriptions of the herniation versus the bulge.

Speaker 00: 9:37

All right. So I kind of interrupted you. I got off on the disc herniation thing. Any other myths or misconceptions you wanted to cover?

Speaker 02: 9:45

So one other one would be that... If you have one back surgery, you're always going to need more back surgeries. So that can be the case, but it varies. So it's most common when you have a fusion in the spine. And we think when two bones are healed together, that's going to translate extra stress to those adjacent levels of the fusion. So what that tends to look like is approximately a 30% chance that down the road in about maybe 10 years, give or take, that you might have some wear and tear at those adjacent levels and you might need another surgery down the road but it's not a guarantee. So some patients go on never have another surgery some within a handful of years start to see that wear and tear and pain returns and we have to extend that fusion up. So it can happen but it's not as common as what patients you know think in their minds I will have to eventually have more. So one final misconception I wanted to address is that A back fusion will leave you stiff or limited in your long-term activities. And while that does depend on how many levels are fused and things of that nature, the majority of the time for a one or two level fusion, that's not the case. We think of common or popular athletes. So Tiger Woods, he actually had a lumbar fusion in 2017. He still plays golf. And most of us aren't doing those types of activities. And we think of Peyton Manning. He had a cervical fusion. He returned to the NFL. So these are things that you can have these types of surgeries and go back to normal activity, go back to your job, live your normal lifestyle. But that's something a lot of patients are concerned about with needing a fusion is what their long-term or their future will look like. So I hope that clarifies those questions patients have.

Speaker 00: 11:41

All right. Well, let's talk about what kinds of issues can surgery help and which ones can it not?

Speaker 02: 11:49

Yeah. So, The biggest thing here would be axial pain versus radicular pain. So to break that down, what axial pain means is it's staying in the midline. So if you come in and you say, I have this pain, it stays right in the middle of my low back. It's been there for 30 years. It comes and goes. That is not something that generally speaking surgery is going to help because that's more axial pain. It could be from a multitude of factors. You know, it could be musculoskeletal, could be arthritis, things of that nature. Now, if you came in and said, for the last three or four months, I've had this severe pain shooting down my leg, we see on the MRI, you have a disc herniation, it's causing pressure on that nerve in the same distribution down the leg. Well, that would be a good indication for surgery, because we know if we take that pressure off of that nerve, the pain in the leg is going to get better. So that's something that is very cut and dry. Versus in the back, there could be many things contributing to your back pain. And so it's a harder problem to say, yes, we can fix that. We know the clear source of that pain. So the surgeries tend to work better when there is a component of nerve involvement versus when it's all in the back.

Speaker 00: 13:13

So if your back hurts, surgery might not be your option. But if your leg hurts because of some nerve pain caused by your back. Okay. So it's not as cut and dried as someone who needs a knee replacement, a hip replacement. It's not just, we'll just take this out, put the new part in and it's all good.

Speaker 02: 13:30

Exactly.

Speaker 00: 13:31

Yeah.

Speaker 02: 13:32

And another thing, oftentimes what used to be done is if anybody had back pain, general back pain, they had imaging and maybe it showed that one of their discs was degenerating, then we used to fuse. So that was something done in the past, but then over time, patients would come back in. My pain's still there. It's not getting better. And over time, they kind of came to the realization that just because there is evidence of a degenerative disc doesn't mean that a fusion is going to help. There's actually a big variability in the response. So maybe 50% of the time it could, 50% of the time it could not help. So it's not usually a first line of treatment. There are many other things that we recommend doing first to try Okay.

Speaker 00: 14:20

So how has back surgery changed in terms of the technology, the recovery rates?

Speaker 02: 14:27

So the very biggest thing would be just the techniques. So surgery has become minimally invasive. And there's so many new technologies every day. But the biggest thing now is with those minimally invasive techniques, the recovery is so much quicker. You know, there's less exposure in surgery. so we don't have to damage as much muscle and tissue to get down to the areas of pathology. So the recovery is better, less pain, you know, things like that.

Speaker 00: 14:58

And there's no, are there robotic? I mean, we know that there's robotic assist for lots of different kinds of surgeries, orthopedic, general surgery. Are there robotic surgeries for back?

Speaker 02: 15:08

So they do have spine robots. We aren't currently using those, but, you know, it is something that we're always looking at, especially at conferences that we attend annually. One thing we do use is what's called spinal navigation. So it's actually a CT scan that we take intraoperatively. And then we use that image in real time while we're putting in hardware for fusions. So screws, things of that nature. And we can actually check the trajectory of where we're placing the screws to make sure we're in a good location, make sure everything is lining up properly. We can take a CT scan again after the screws are in place to ensure proper placement. So that's something that has really helped as far as technology with surgeries.

Speaker 00: 15:56

Okay. So at what point does someone need to see their medical provider and then eventually a specialist like you for back pain?

Speaker 02: 16:04

So generally speaking, you know, if you wake up after you've done some yard work and you have a backache, I'll typically recommend that you try some over the counters, you know, give it a day or two, rest the back see if things are going to get better if the pain persists you know if it's unbearable see your primary doctor but if it's more of an ache or a sore sore back give it another week or two if it's lingered for more than that period of time get in with your doctor usually they will try something like a steroid pack they might do some general x-rays the time that it would be to see me would be if you've gone through maybe some medications maybe some some physical therapy and things are persisting or you start to develop any sort of neurological issues say the leg starts getting weak or you're tripping or you're having severe nerve pain and and it's unbearable or there's progressing weakness so those would be reasons that they might send you to our office generally we'll want an MRI done by your primary so we have an idea of what the pathology is so that we can better treat the condition certain conditions conditions can be treated with injections. Certain conditions might be more surgical. So the MRI helps to determine that along with the physical exam and the history taken at the visit.

Speaker 00: 17:29

So when someone comes to see you, they've gone through their primary care, none of those things that help, and now they're in your office, what should they expect when they come see someone like you?

Speaker 02: 17:40

So generally what we'll start with is just a discussion. So I ask all the questions. I want to know every detail of their, you know, their history with the spine. Have they had surgery? How long has the pain been going on? What have they tried? What's worked? What hasn't worked? When is the pain worse? Is there anything that they've found that's made it better? What other factors might there be? Do they smoke? Do they take any sort of medications to treat the pain? And then generally, we'll start the exam. And that gives me a lot of information as far as is there weakness? Is there sensory loss? We'll check reflexes, stress, all of that and then typically I will review all the images if there's x-rays, CTs, MRIs and I try to break it down to make it very simple for the patient to see what's going on with their own eyes and to make everything we talk about make sense. So then I'll break down and just describe the different options that we have to treat it and generally I'll start with the most conservative all the way up to what options potentially we could have surgically and just in creating the patient that it's always better to exhaust all conservative management first and then we'll make a decision together what the conservative treatment will look like moving forward but generally it involves ordering some sort of therapy maybe trialing an injection potentially recommending surgery things like that

Speaker 00: 19:08

so at what point does it become yep surgery is what's going to be best for this person

Speaker 02: 19:14

so generally we'll want the pain um to be at a point where the That would be a reason to consider surgery. And lastly, if they have failed other conservative options. So they've gone through therapy, maybe they've tried a few rounds of injections and they either were effective or they became less effective over time. Those would all be reasons that we could then move forward with discussing surgery.

Speaker 00: 20:08

So you talked about some of the surgeries you and Dr. Nardone do. So run us through, you know, you talked about fusions, you've talked about other things. What kinds of surgeries do you perform here

Speaker 02: 20:19

so some of the most common would be what's called a laminectomy so that is a type of a decompression where we remove pressure from the nerves another would be like a micro discectomy that is for disc herniation so we take that piece of disc away off of the nerve we do quite a bit of fusions so that's where we heal two bones together to become one that also involves freeing up the nerves if there's any underlying pressure. So those are some of the more common procedures that we do. And those can be performed in any area of the spine. And we treat the cervical, thoracic, and lumbar spine.

Speaker 00: 21:01

So those people come to you and say, I've had back pain for 25 years. What's going on? And is back surgery going to help them? So

Speaker 02: 21:09

most of the time, if patients have had longstanding back pain, it tends to be, it could be a multitude of things. but oftentimes I find that it's more related to underlying arthritis so one of those things would be degenerative disc disease and that type of pain can cause symptoms mostly in the low back sometimes it radiates to the buttocks but tends to be in the low back it's worse when you sit too long you stand too long any position too long you frequently have to move around you have to shift and that stems from those discs losing that good hydration so as they begin to dry up you have to that pain can wax and wane. The pain can start to flare and it can be quite severe. A lot of patients will come in with a flare from that type of pain and say, I couldn't walk, I had to crawl to the bathroom. And sometimes we think the severity of pain is equal to there has to be something wrong and you do an MRI, there's no nerve compression, but we do see that there's arthritis in the disc. Although there is arthritis seen, surgery isn't the best option for that like we discussed because maybe 50% of the time it helps maybe 50% it doesn't or you could even be worse or you could be set up to need more surgeries down the road so that is something that's the more common cause of long-standing back pain is due to underlying arthritis and usually it's recommended to treat that conservatively therapy anti-inflammatories you know maintaining good core strength weight loss things like that and just managing it the best that we can add Adjunct treatments can help like chiropractic care, inversion tables, things like that as well, but those generally aren't surgical conditions.

Speaker 00: 22:56

Okay, what about sciatica? I know a lot of people suffer from that. What is it and can surgery help with that?

Speaker 02: 23:06

So it's compression on the sciatic nerve is what that term refers to, but in general, if someone's having nerve pain and it is related to underlying pressure seen on a an MRI on that particular nerve, then yes, that is a good indication for surgery. It's pretty cut and dry. We take the pressure off of that nerve and the pain will get better. You know, of course it can take time for that nerve to heal and recover, but when that happens, the nerve pain improves.

Speaker 00: 23:35

What about bone spurs? You hear about bone spurs in your feet, maybe in your knee. Can you get them in your spine?

Speaker 02: 23:41

You can, yes. Oftentimes they come off of the disc. So as the disc starts to degenerate and wear and tear, the body tries to contain that disc. So it doesn't want that disc to bulge beyond its borders. So it creates these spurs to try and contain it on its own. And in and of itself, a spur is not a big deal. But if it begins to cause compression on a nerve, then you begin developing nerve pain because of that, then it is something we can address. So in general, if you're told you have a spur, but you're not having any symptoms, it's nothing to be overly concerned about. It's more if it begins to cause nerve compression and symptoms in that regard.

Speaker 00: 24:25

So are there certain vertebrae or areas of the back where they herniate more than others?

Speaker 02: 24:31

Yes. So the lower portions tend to be more problematic. So that's the L4-5 and the L5-S1. They're more of the weight bearing areas in the spine. They carry a bit of a heavier load there. So those are the two more common areas that we see problems arise. All

Speaker 00: 24:50

right. Well, let's talk a little bit. Let's switch gears. I want you, when you are out and about and you see people doing things, you're like, oh, don't do that. What are some of the worst activities or actions that you see people doing that are so bad for their back that could result in them having to come see you at some point?

Speaker 02: 25:10

So one of those actually is smoking.

Speaker 00: 25:13

Okay. I was thinking it was going to be some physical collectivity but

Speaker 02: 25:17

that too but a lot of the patients we see that have fairly widespread degeneration in the spine or fairly widespread pathology I look in the chart and maybe they've had a long-standing history of tobacco use so smoking plays a role in the spine because it actually deprives the disc of oxygen so over time if you imagine that disc isn't getting its good oxygenation it's going to deteriorate quicker and there's going to be more arthritis built up so So those patients do tend to have more pathology than somebody who doesn't smoke. And if we did have to do a surgery on a smoker, there is a higher rate that they wouldn't fuse, which we call non-union. So that's important to even be considered a surgical candidate, that if you smoke and you're going to require a fusion, that we really encourage patients to quit smoking just for their long-term healing. So how come they won't fuse together because you smoke? Because it does affect the healing process also. Yes. Yes.

Speaker 00: 26:21

So I'm going to ask real quick, when you fuse someone's spine together, they fuse together like with screws. Okay. So there's like a mechanical thing and they're holding those together. Okay. All right. So let's talk about, so you smoking, but like what other things are bad for our back?

Speaker 02: 26:38

So that's, that's one. The other would be as far as like lifting goes if you see patients lifting with their back you actually want to focus more on lifting through your lower body the legs that type of thing I would say any activity that you do you want to avoid engaging anything strictly with the back you want to use the core so if you're not strengthening the core and focusing on that strength then you're focusing just on the spine doing all the lifting the core is this group of muscles that acts like a corset to the spine so it's very supportive anyone that's doing any sort of high impact activity but they're not focusing on first stabilizing the core you could experience pain so a lot of times patients will come in when golfing season starts having all this back pain and my husband is one of those and you know he says why is my back killing me well you never work the core then you begin doing an activity where you're constantly twisting twisting twisting and using those muscles but they're not strong. So it is putting extra strain on the back. So that's something I'll encourage patients to do is just to make sure that you're really focusing on stabilizing the core before doing any sort of impactful activities to help reduce that risk of injury or strain. Another thing that's important for spine health would be maintaining a healthy weight. So the more weight we carry is more load that the spine has to bear, just like the joints, you know, their weight bearing. So the less weight that we do carry on the the body, you know, the less strain we're going to put on our spines. If patients are stomach sleepers, that's not great. It's best to sleep on your side or on your back. Use pillows where you need to support. That is something that I commonly get asked is what pillow should I use or what mattress should I use? And there's no specific brand that's superior. The main thing is something that's supportive. And then as far as alignment, whatever position you're sleeping in, Make sure that your spine is in a neutral alignment. So you don't want your neck on three pillows, you know, and be really, really high up. But you also don't want one flat pillow where your neck is kinked to the side. So something that's going to keep the spine in a generally neutral position that's supportive. is usually the best.

Speaker 00: 29:02

All right. What about women who wear high heels all day? Bad for our back? Yes.

Speaker 02: 29:06

Yes. You want to wear shoes that are supportive, have good cushion, things like that. Over time, that can affect the back, yes.

Speaker 00: 29:15

So is there anything we can do or take to help with our disc health? Because you said it was jelly. Is it cartilage? Or what is it?

Speaker 02: 29:27

So it's a fluid-filled inner area. It's a jelly type formulation. It's called a nucleus pulposus is what the inner portion and the outer is called your annulus fibrosus. So it's actually a fibrous area outside of it. So really, I mean, you can try to stay hydrated and those types of things. But oftentimes, the rate of degeneration, there's a genetic component. There's an environmental component. Like I said, don't smoke if you smoke. That is one big indication that you're one big thing we seen that is linked to degeneration of those discs, obviously maintaining a healthy weight. But those are kind of the big things that we can do. So but there's not any big supplements. No, not yet. There's all these things in the works, you know, trying to work on ways that we can regenerate that tissue, ways to improve that tissue, things like that. But obviously, things can get stiff. And the more you move, that's going to help keep things mobile, keep things flexible, lubricated with the joints But the more that we sit, the more we're sedentary actually can cause more problems. So some patients say, well, if I walk, if I move, it hurts more. And that can be the case. But we also have to maintain that mobility in the joints for the joint health. So stay flexible, move.

Speaker 00: 30:49

All those things we know we should do that we sometimes don't do. Well, Kayla, this has been really interesting. I want to thank you for taking time out to talk to us. And now we know if we're a candidate for back surgery or not. And if we are, now we know who to go see. Yes.

Speaker 02: 31:03

Well, thank you so much. I appreciate you taking the time.

Speaker 00: 31:06

All right. Thank you. As Kayla said, the decision to have back surgery is not cut and dried like other types of surgeries. It really depends on the type and the source of the pain. A few reminders about back health. Smoking makes back pain worse and recovery more difficult if you have surgery. Strengthen your core. It helps protect your back and when you lift, use a strength in your legs to lift and not your back. Finally, if your back is sore after an activity, give it a rest for a few days. and take an over-the-counter anti-inflammatory. If the pain continues, start by seeing your primary care provider. To learn more about Kayla and neurosurgery at Sarah Bush Lincoln, visit our website at sarahbush.org under Find a Doctor. And remember to consult your health care provider as the information shared in this podcast is for informational purposes only. Thank you so much for tuning in and don't forget to subscribe so you can stay updated on when new episodes are available i hope you have a fantastic day