SPINE AND NECK SURGERY: MAKING A DECISION THAT S RIGHT FOR YOU

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1 1. GET THE FACTS: Back and neck pain affects 8 out of 10 people at some point in their life. Acute back and neck pain comes on suddenly and usually lasts from a few days to a few weeks. Chronic back and neck pain is typically described as lasting for more than three months. Back and neck pain can take on a wide variety of characteristics: The pain may be constant, or intermittent. It might occur only with certain positions or activities. The pain may remain in one spot or radiate to other areas. The pain may be sharp, a dull ache or a burning sensation. Back or neck pain can be caused by a number of factors: Inherited factors. Injuries (e.g. falls, sports). Effects of aging. Arthritis. Disc degeneration that can be accelerated by smoking, occupational factors, bad posture or lack of exercise. Osteoporosis, which is caused by bones losing their strength over time. It alone cannot cause back and neck pain but can weaken the spine so that normal strain or minor trauma causes fractures. Trauma: Injury severe enough to cause a vertebra to break can occur with a fall from a tall height in which the person lands on his or her feet or buttocks. It can also occur in a person involved in a car accident. The primary reason for back and neck surgery is to get relief from pain in those affected areas. For many people the result is less pain. Less pain comes with additional benefits including: Increased physical activity. Improved mood. A decreased need for pain medicines with fewer drug side effects. Ability to go back to work. COMMON CERVICAL (NECK) CONDITIONS INCLUDE THE FOLLOWING: Cervical Disc Disease: Pressure on the spinal cord in the cervical region can be a very serious problem because virtually all of the nerves to the rest of the body have to pass through the neck to reach their final destination (arms, chest, abdomen, legs). This can cause radiating pain, numbness or weakness in your shoulders, arm, and hand. Aging can cause the discs to lose fluid, collapse, and sometimes rupture. As the disc deteriorates, it affects the structure of the vertebrae. The structural changes can put pressure on the spinal cord or spinal nerves, resulting in pain and loss of function. Cervical Stenosis: This condition occurs when the spinal canal narrows and compresses the spinal cord, and is most frequently caused by aging. The discs in the spine that separate and cushion vertebrae may dry out. As a result, the space between the vertebrae shrinks, and the discs lose their ability to act as shock absorbers. Cervical Radiculopathy: This describes pain and neurological symptoms caused by any condition that irritates a nerve in the cervical spine (neck). The symptoms can radiate along that nerve's pathway into the arm and hand. Certain neck movements (bending, side to side, rotation) may increase the pain. The type of pain may vary dull, severe or sharp. CERVICAL PAIN CAN BE RELIEVED IN A VARIETY OF WAYS INCLUDING: Medications: The first line in treatment for cervical disc disease is over-the-counter pain medications, including acetaminophen (Tylenol) and nonsteroidal anti-inflammatory medications such as ibuprofen (Motrin, Advil) and naproxen (Aleve). These medications can help reduce pain and inflammation. Your doctor might prescribe steroids or narcotic painkillers if over-the-counter medications aren't working. Therapy: Physical therapy is another treatment option for cervical disc disease. The therapist can use cervical traction, or gently manipulate your muscles and joints, to reduce your pain and stiffness. The physical therapist can also help you increase your range of motion and show you exercises and correct postures to help improve your neck pain. Anterior Cervical Discectomy: This surgical procedure is performed on the neck to relieve pressure on one or more nerve roots, or on the spinal cord. In the procedure, the intervertebral disc and bone spurs are removed. The space left between the vertebrae may be left open or filled with a small piece of bone or device through spinal fusion. PAGE 1

2 1. GET THE FACTS (continued): COMMON LUMBAR CONDITIONS INCLUDE: Lumbar Disc Disease: When we age, intervertebral discs may lose fluid and become dried out. Fragments of disc material can press on the nerve roots that are located behind the disc space. This can cause pain, weakness or numbness. Trauma can also cause a normal disc to herniate. Degenerative Spondylolisthesis: A condition in which one of the bones of the spine (vertebrae) slips out of place onto the vertebra below it. If it slips too much, the bone might press on a nerve, causing pain. Spinal stenosis Currently, it is estimated that about 400,000 Americans, most over the age of 60, may be suffering from the symptoms of lumbar spinal stenosis. As a result of many years of wear and tear on parts of the spine, the tissues nearest the spinal canal sometimes press against the nerves resulting in pain in the buttocks or legs. Symptoms may occur as a result of spinal stenosis: pain, numbness, tingling, and weakness. One particularly worrisome symptom is bowel or bladder dysfunction (inability to control urination or bowel movements). This can be a symptom of cauda equina syndrome and should be treated as a medical emergency. Cauda equina syndrome may require immediate surgery to decompress (create more space) the area of the spine that is seriously affected by nerve compression. LUMBAR PAIN CAN BE RELIEVED THROUGH A VARIETY OF PROCEDURES INCLUDING: Laminectomy: A surgical procedure to relieve pressure on the spinal nerves. A laminectomy involves removing a section of the bony covering over the back of the spinal canal. This takes pressure off the spinal nerves, often providing pain relief. Kyphoplasty This procedure restores the size and strength of fractured vertebra. This helps realign the spine and reduce pain. Kyphoplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, which involves an incision and the use of larger instruments, kyphoplasty is a minimally invasive procedure. It requires a small opening in the skin and small instruments, lessening the chance of bleeding, infection and injury to muscles and soft tissues. Discectomy: A disc is the material between the vertebrae that cushions the spine. A discectomy is the surgical removal of a herniated or damaged disc pressing on a nerve root or the spinal cord. Discectomies can sometimes be performed arthroscopically through a smaller incision using specialized tools with local anesthesia. An open discectomy involves a larger incision but allows the surgeon the greatest ability to see and explore the surgical site. Lumbar Decompression: This is the most common surgery in the lumbar area of the spine. The laminae (roof) of the vertebrae are removed to make more space for the nerves and reduce pain. Spinal fusion: This is done to permanently join together two or more bones in the spine so there is no movement between them. The surgeon will use a graft (such as pelvic bone or bone from a bone bank) to hold the bones together. A synthetic bone substitute can also be used. Fusion may or may not involve use of hardware such as plates, screws or cages. Generally speaking, the hospital stay after back or neck surgery is anywhere from one to two days. This is followed by a period of rehabilitation. The amount and type of rehabilitation needed depends on the surgical approach used, your bones and physical condition before your back or neck surgery, any post-operative pain that might limit your ability to do therapy and your willingness and ability to work hard between your visits to the physical therapist. No surgical procedure is without risks. The majority of these risks can be substantially reduced with simple preventive measures. Your surgeon and anesthesia provider will be happy to explain the many preventive measures that he/she takes to keep your risks as low as possible, and will be happy to share his/her current complication rates. The most common post-operative complications after back or neck surgeries are: Excessive bleeding. Problems with anesthesia. Chronic neck or arm pain. Persistent swallowing or speech disturbance. Leakage of cerebral spinal fluid. Infection. Nerve damage. Inadequate pain relief. The following back or neck pain symptoms may be indications of a serious medical condition and anyone with these should seek immediate medical care: Difficulty passing urine or having a bowel movement. Progressive weakness in the legs. Severe, continuous abdominal and low back pain. PAGE 2

3 2. WEIGH YOUR OPTIONS: In the early stages of back or neck pain, there are several good options for the management of pain. These include: LIFESTYLE CHANGES: Diet: Weight loss helps to relieve the stress placed on the back and neck during activity. A healthy body mass index is between 18.5 and Even if you are currently at a healthy weight, your surgeon may recommend an anti-inflammatory diet that is rich in antioxidants and vitamins C,D and calcium to improve the quality of your back health. Exercise: Research has shown that exercise improves muscle strength. A well-balanced exercise program should include strengthening exercises to help rebuild muscle and core, flexibility exercises that improve range of motion, balance exercises that encourage safe movement and endurance exercises that improve cardiac health. Your surgeon can recommend the exercise program that is safest and most effective for you. Smoking Cessation: Bone is rich in tiny blood vessels and requires a significant concentration of oxygen from the blood to constantly mold and repair itself. Over time, because of lowered oxygen concentrations, smokers' bones lose density. They fracture more easily and take up to 80 percent longer to heal. Your surgeon can recommend products and programs that can help you quit. USE OF MEDICATIONS: Oral medications: Anti-inflammatories such as naproxen and ibuprofen are the most commonly recommended medications for back and neck pain, and have been shown to be one of the most effective medications. Stronger anti-inflammatories such as Celebrex and Tramadol are also available but require a prescription. All anti-inflammatories (NSAIDS) have the potential to cause increased bleeding, especially in the stomach and gastrointestinal tract, and must be used with caution over long periods of time. Opioid Narcotics: When anti-inflammatories no longer work or cannot be used due to side effects, oral narcotics may be prescribed. Because they are highly addictive, they are prescribed with extreme caution and monitored closely by your physician(s). Epidural or transforaminal injections: If symptoms continue to limit your ability to function normally, your doctor may suggest an injection into the spine to help with pain. Your doctor may recommend facet injections into the joints of the spine. A series of injections may be more helpful to provide a temporary decrease in pain. Use of Mechanical Aids: Canes/Walkers: Walking aids, such as canes and walkers, can help to 'share' the stress being placed on the back and neck, thus reducing the wear and tear and decreasing the discomfort. They can also help with balance to prevent falls. Braces: Bracing may provide some help especially when the back or neck is painful or unstable. Braces that are made to fit may be more comfortable and effective but they are more expensive than off-the-shelf braces or supports. There are also unloading braces to help relieve pressure on the discs, nerves and joints of the spine. OTHER THERAPIES Transcutaneous Electrical Nerve Stimulation (also called a TENS unit): This procedure works by sending stimulating pulses across the surface of the skin and along the nerve strands. The stimulating pulses can help prevent pain signals from reaching the brain. Therapeutic massage: Therapeutic massage involves the manipulation of the soft tissue structures of the body to prevent and alleviate pain, discomfort, muscle spasm and stress, and to promote health and wellness. Spinal cord stimulators: Spinal cord stimulation (SCS) is a pain relief technique that delivers a low-voltage electrical current continuously to the spinal cord to block the sensation of pain. SCS is the most commonly used implantable neurostimulation technology for management of pain syndromes. PAGE 3

4 3. CONSIDER YOUR FEELINGS: Many different things might factor into your decision to have back or neck surgery. These are all things to consider when making your decision: Age: o Many younger patients with back and neck pain are concerned about having back or neck surgery because they may later require revisions that are progressively more difficult. o Many older patients are concerned about undergoing surgery due to frail health. A pre-surgical clearance will be done by specialists who can help decide if back or neck surgery will increase your risk for negative outcomes. These specialists will work with your surgeon and with you to make sure that surgery is right for you. Fear of hospitals or medical procedures: Many people are afraid of hospitals and procedures. Many things can affect those emotions, such as education about both procedures and your hospital stay, past experiences and anxiety disorders. Fear can create many problems, especially when patient participation is so important. Many of those fears can be reduced simply by talking to someone who is armed with information to be able to address your fears and concerns. Finances: Although insurances generally cover the lion share of expenses, there are often copayments for the surgery and the medications and therapies used afterwards. In the 90 days prior to your surgery, there will be approximately $1,500 worth of expenses such as physician visits, routine laboratory studies and x-rays. If your insurance covers 80%, you will be expected to pay approximately $300. The procedure itself costs upwards of $60,000, so you would most likely pay the balance needed to fulfill your deductible. (For instance, if your deductible is $500, that out-of-pocket cost would be approximately $200, but if your deductible is set high ($2,000), you will need to pay $1,700). Post-operatively, you may have limits on the amount or type of physical therapy or the kinds of medical equipment that your health plan will allow. It is important to contact your insurer to find out exactly what things they will and will not cover. If you are concerned about your ability to cover costs, your physician's office staff and/or the hospital finance department can assist you with understanding your options and finding a payment solution. Availability of help at home: After back or neck surgery, some additional help may be needed at home. Often, extended family members do not live in close proximity or they work hours that prohibit them from helping. There are many options to help you, ranging from a short post-operative admission at a skilled nursing facility to assistance with meals or cleaning facilitated through various social agencies. The hospital discharge planners have extensive knowledge of these options and will work with your surgeon and your insurers to ensure that you have the support you need when you go home. 4. YOU DECIDE! Your decision to have back or neck surgery should be made after weighing the evidence. Evidence comes from studies that look at how well treatments and tests work and how safe they are. For many reasons, some studies are more reliable than others. The better the evidence is - the higher its quality - the more we can trust it. The information in this flyer is based on the best available evidence; evidence that comes from trusted medical sources such as the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), the National Association of Neurologic Surgeons (NASS) and the American Academy of Neurologic Surgeons (AANS) who have reviewed large cohorts of data using strict guidelines. Unfortunately, evidence cannot predict what is going to happen in your case. When evidence tells us that 1 out of 100 people who have a certain procedure may have a certain result, there's no way to predict if you will be the one with a negative outcome, or one of the 99 who will not. PAGE 3

5 5. QUIZ YOURSELF Is back or neck pain preventing me from working or doing the activities of daily living? Is back or neck pain preventing me from enjoying my family and friends? Is my back or neck pain so severe that I can no longer manage it without narcotic pain relievers? Have I tried alternatives to back or neck surgery? Do I understand the benefits of back or neck surgery? Do I understand the risks associated with back or neck surgery? Am I prepared to do the work before and after surgery to prevent complications and rehab my back or neck? Am I comfortable with my surgeon and his/her outcomes? Will I be safe at home in the first few days after my surgery? Do I have unanswered questions about back or neck surgery? You are an important member of the health care team. If you still have questions remaining, talk to your surgeon. For additional information, you may also contact the Director of Orthopaedic Services at Mountain Vista Medical Center at (480) PAGE 4

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