Degenerative Disc Disease Surgery

This blog entry is part of a series of interview responses provided by Kevin Macadaeg, MD, a minimally invasive spine specialist with Indiana Spine Group. Dr. Macadaeg was recently interview about back pain and spinal treatments.

What are some of the different causes or reasons for chronic neck or back pain? What would you say is the most common cause of back or neck pain?

The most common causes of chronic neck or back pain are degenerative disc disease and degenerative spondylosis (degeneration of the spinal joints, development of bony spurs, disc degeneration and calcification of spinal ligaments).

Other causes include herniated disc, spinal stenosis (narrowing of the spinal canal) and spondylolisthesis (slipping of a vertebra).

What are the different options available to treat this type of pain?

Recently Kevin Macadaeg, MD, a minimally invasive spine specialist with Indiana Spine Group was interviewed for a magazine article about back pain and spinal treatments. The following few blogs will highlight responses to the questions asked by the reporter.

What is chronic pain, and how is it different than acute pain?

Acute pain is considered “physiologic.” That means it is present when there is an underlying problem such as an acute injury, certain sicknesses and diseases. This type of pain is usually self-limited, and resolves when the underlying primary problem is healed.

Chronic pain is considered “non-physiologic.” It is present despite the fact that the underlying problem has healed or stabilized. Examples include peripheral neuropathy, degenerative disc disease, arthritis and cancer. Chronic pain commonly has associated emotional effects including depression, anger, anxiety; and physical effects including loss of appetite, weight gain or loss.

I co-authored a book chapter on “Cervical Disc Replacement”, that has been recently published in Rothman Simeone The Spine – 6^th Edition.

The Spine is a continuing medical educational resource for spine surgeons and highlights state-of-the-art spine treatments and spine surgery techniques. In addition to the text, there is also a video resource for physicians highlighting different surgical techniques and procedures.

Some sections of this book include: Basic Science, Spinal Diagnosis, Surgical Anatomy and Approaches, Thoracic and Lumbar Disc Disease, Minimally Invasive Surgery, Spinal Stenosis, Spinal Fusion and Instrumentation and more. For more information about The Spine and a table of contents, visit this link.

Back Talk | A Comprehensive Review and Practical

Approach to Spinal Diagnosis and Treatment

One series of sessions at Indiana Spine Group’s continuing medical education / continuing education spine symposium will focus on the diagnosis of spinal disorders.  In one series of talks, speakers will highlight key issues and steps critical to spinal diagnosis. Topics will include:

• Spinal Anatomy – differentiating between normal and abnormal spinal anatomy (Speaker: Jonathan Gentile, MD, minimally invasive spine specialist with Indiana Spine Group)

• Diagnostic Pearls – identification of the critical components of the physical exam, and essential elements of the diagnostic work-up (Speaker: John Arbuckle, MD, minimally invasive spine specialist with Indiana Spine Group)

• Common Spinal Disorders – diagnostic indicators for disorders such as herniated discs, degenerative disc disease, spinal stenosis, spondylosis and more (Speaker: Kevin Macadaeg, MD, minimally invasive spine specialist with Indiana Spine Group)

• Disorders of the Bones – a review of conditions such as osteomalacia, Paget’s disease, spinal arthritis and osteoporosis (Rashid Khairi, MD, FACP, FACE, an endocrinologist with Diabetes & Endocrinology Associates) 

• Uncommon and Benign Disorders – a discussion of disorders such as infections and vascular disorders. (Kenneth Renkens, MD, FACS, spine surgeon with Indiana Spine Group)

•  The Role of EMG – the role and indications of EMG in the diagnosis of cervical and lumbar radiculopathy. (Larry Lett, MD, Center for EMG and Neurology)

A recent blogger submitted a few questions about degenerative disc disease, and asked about treatment options for the lumbar spine. 

The blogger asked the following:

What about dynamic stabilization devices as an alternative to lumbar fusion? I have been doing some online research, hoping to get plugged into a 522 study, or otherwise explore whether insurance might cover something like this in my situation. (2 degenerating discs.)

Paul Kraemer, MD, a spine surgeon with Indiana Spine Group responded to these questions.

First, there is no perfect treatment for degenerative discs. The technology of motion stabilization is still very much in its early infancy, and at this point that is probably not the best solution.

There are two categories of implants that exist, disc replacement and motion stabilization, but trials have had problems and neither is currently being implanted.  One motion stabilization implant, sought to minimize motion of the disc to prevent pain and decrease revision surgery, but no definitive proof for either of those claims exists, and they have run into recent trouble with the FDA for their longer term data. Another motion stabilization concept, facet replacement devices are motion preservation devices aimed at facet joints, and at least one recent trial was ended early by the FDA.

Disc replacement in the lumbar spine has been done for over 20 years and works well in appropriately selected patients.  This procedure is FDA approved, but insurance companies frequently refuse to acknowledge convincing data. The results for this surgery seem very reproducible, but it’s only approved for single level disease with healthy facet joints.

All of this skips over the point that back surgery is usually not the first or best answer for back pain, and many people with degenerative discs have little or no pain. It's always recommended to talk to a spine surgeon to see what your specific treatment options are.

In respect to web sites that provide spine specific information – a few very popular sites are Spine Universe and Spine Health.  

Medline Plus defines kinematics as a discipline of physics that deals with the aspects of motion, separate from the considerations of mass and force. As a physician, I don’t really think of myself as a physicist – but recently I had the opportunity to study kinematics.

Recently I participated in a study to evaluate “cervical kinematics”. The purpose of cervical kinematics is to understand the motion of the cervical spine. Cervical kinematics has evolved as a result of the spine surgery procedures that alter the pathological structure of the cervical spine. In looking at the cervical spine and motion – cervical kinematics evaluates how the anatomical alterations affects an individual’s motion.

The study that I participated in evaluated the affects of cervical disc arthroplasty. This spine surgery procedure, which is relatively new and just recently received FDA approval, is a spine surgical alternative to standard spinal fusion in the surgical treatment of degenerative disc disease. With cervical disc arthroplasty, the damaged cervical disc is removed and an artificial cervical disc is implanted. The purpose of this study was to determine how movement is affected by the artificial cervical disc. In this study radiographic films were used to measure movement (distance) in the flexion and extension of the cervical area (neck) and it also utilized a computer assisted model. The results of this study were published this past June in Techniques in Orthopaedics. 

In a prior blog entry, I talked about study results for the Bryan cervical disc (artificial cervical disc used in arthroplasty).  This procedure is a spine surgical treatment option for degenerative disc disease.

Degenerative disc disease is a natural result of the aging process and is a condition where one or more of the vertebral discs weaken.  For a detailed definition and the symptoms of degenerative disc disease, visit this link.

I recently co-authored a chapter on instrumentation that was published in a book entitled Cervical Spine Trauma. This chapter was entitled Cervicothoracic Junction Instrumentation. 

Additionally, I recently wrote a chapter for a Brazilian spine society book. The chapter was on degenerative disc disease, and was included in “Conceitos Avancados em Doenca Degenerativa Discal Lombar”.

We are all aware of the dangers of smoking. Cancer, increased risk of stroke, coronary heart disease, are only a few of the risks. 

This spine wellness blog entry – will focus on smoking and your spine.

When you think of smoking and your overall spine health:
 

• Smoking contributes to early and more severe degenerative disc disease as a result of the nicotine blocking the transportation of oxygen and other important nutrients to the spinal discs. (This is true for nicotine in any form). When spinal discs are deprived of oxygen, the discs are less able to repair themselves which leads to earlier collapse than what is seen in non-smokers.

• Smoking results in slower healing times for individuals that undergo spine surgery (back surgery).

• Female smokers who are postmenopausal, have lower bone density than women who have never smoked. This lower bone density can increase the risk for osteoporosis and fractures (e.g. hip fractures).

The good news is when you stop smoking, this helps to reduce your health risks. Additionally, there are many resources to help individuals stop smoking and the American Lung Association provides a lot of programs for both adults and teens. For more information about how to stop smoking, visit this link and talk to your physician.

I recently co-authored a book that is now available on Amazon or through the publisher.  The book, entitled Spinal Arthroplasty: The Preservation of Motion, provides detailed information about spinal arthroplasty.  This medical education book includes information about cervical artificial discs and lumbar artificial discs that are used in the spine surgical treatment of cervical and lumbar degenerative disc disease.

A few chapter titles include: 

• History of Spinal Fusion
• History of Motion-Sparing Surgery
• Spinal Anatomy
• Spinal Biomechanics
• The Effects of Fusion and Motion Sparing Procedures on the Biomechanics of the Spine
• Biomaterials in Spinal Arthroplasty
• Total Disc Arthroplasty: Clinical Indications and Surgical Approach
• Cervical Arthroplasty: Biomechanics, Design Considerations, Clinical Outcome
  

One spine surgery research study that I participated in - compared the post-operative results of cervical arthroplasty and arthrodesis on approximately 500 patients. The objective of this study was to compare any side effects of patients undergoing a cervical arthroplasty with the implantation of a Bryan Cervical Artificial Disc to those patients that underwent a spinal fusion.

In this study, of which there were 31 institutions where patients underwent spine surgery, there were 242 patients who received the Bryan Cervical Artificial Disc and 221 patients that underwent cervical discectomy and spinal fusion. Patients that participated in this study were over 21 years of age, had single level cervical degenerative disc disease causing radiculopathy or myelopathy as well as a few other clinical indicators. Once identified, these patients were evaluated before spine surgery and post-operatively at regular intervals beginning one and one half months following spine surgery up to 2 years. 

This study concluded that both procedures are safe, and that there is not a significant difference in adverse effects with the newer arthroplasty procedure utilizing the Bryan Cervical Artificial Disc when compared to the traditional surgical option of spinal fusion.

 To read the complete study,link here.

At Indiana Spine Group’s Back Talk continuing medical education symposium, as highlighted in a previous blog entry , there are two educational tracks that will be available for conference attendees on day one.  In addition to the general track discussed in the prior blog, there is a more in-depth track entitled, More Specifics | Spinal Diagnostics and Treatment. 

In this education track there will be a few sessions focusing on the diagnosis of spinal disorders and abnormalities.  One session titled Spinal Imaging | Technology and Diagnosis, will be presented by Stephen Pomeranz, MD. Dr. Pomerance is a radiologist. In this session, Dr. Pomeranz will provide an in-depth look at spinal imaging technologies and highlight the latest developments in spinal imaging technology and their applications in spinal diagnostics.  Additionally, using case studies, he will review radiological finds and diagnostic indicators. 

The second session of this educational track will focus on The Electrodiagnostic Evaluation, and will be presented by physical medicine and rehabilitation specialist Dr. Shashank Dave.  During his presentation, Dr.Dave will discuss the role and application of electromyography in the diagnosis of spinal disorders and diseases.  Additionally, he will review case studies which utilize electromyography and identify specific diagnoses. 

Another session presented for the in-depth track will focus on Diagnostic and Therapeutic Injections of the Spine.  This will be presented by minimally invasive spine specialist John Arbuckle, MD.  During this session Dr. Arbuckle will review and differentiate between the different type of therapeutic injections and will review the treatment efficacy of injections, the clinical protocols, indications and expected outcomes. 

The last session of this continuing education track will highlight spine surgery, and is entitled Surgical Perspectives | Fusion vs Arthroplasty, presented by spine surgeon Rick Sasso, MD.  During this session, Dr. Sasso will provide a detailed analysis of spinal fusion and arthroplasty and he will discuss motion preservation modalities for the treatment of generative disc disease.  He will highlight lumbar and cervical artificial discs as well as review research studies and discuss patient selection, indications and expected outcomes. 

The next series of blog entries will focus on a few spine wellness tips.  Simple solutions that provide health benefits to your spine. 

One popular New Year’s resolution is to go on a diet and lose weight.  Losing weight provides many health and wellness benefits, including spine wellness.  Did you know that obesity is one contributing factor to back pain? 

Spine Wellness Tip #1: Drop Some Pounds 

In May 2009, the Bryan Cervical Artificial Disc received FDA approval.  This approval was previously written about in Dr. Sasso’s blog.  The cervical artificial disc provides an alternative spine surgical treatment for cervical degenerative disc disease.

Dr. Rick Sasso, a spine surgeon with Indiana Spine Group, has been a principal investigator in the studies with this spine surgical device – the Bryan Cervical Disc.  A few of abstracts of his published research studies regarding the cervical disc are available on the U.S. National Library of Medicine / National Institutes of Health web site. 

These include:

• Cervical kinematics after spinal fusion and bryan disc arthroplasty 
  
• Motion analysis of bryan cervical disc arthroplasty versus anterior discectomy and spinal fusion: results from a prospective, randomized, multicenter, clinical trial 
  

I was recently interviewed for a news story that announced the FDA approval of the Bryan™ Cervical Disc. The Bryan Cervical Disc is an artificial disc used in cervical arthroplasty. 

This story also appeared on their web site which generated a few reader’s comments/questions. This blog entry – will address some of those questions. 

Blogger question: Can it be used in the lower back?

The Bryan Cervical Disc can only be used in the cervical (neck area) spine. There are two FDA approved artificial discs for the lower back (lumbar spine). They are: CHARITE Artificial Disc, approved by the FDA in 2004 and the ProDisc. Artificial lumbar discs are a surgical option for some patients who are being treated for degenerative disc disease or other related spinal conditions. These links provides more information about the artificial lumbar disc - (article one and article two).

Blogger question: Does this work for someone who has had a fusion done 10 years ago?

The answer to this is no. When a spinal fusion is performed, two bones are “fused” together; meaning that they are attached. In that this procedure is done with the goal of a permanency – it can not really be undone to have cervical arthroplasty performed. 

In blog discussions about the cervical artificial disc, specifically the Bryan Cervical Disc, it was announced that this disc has now received FDA-approval.  One key advantage of cervical arthroplasty and the Bryan Cervical Disc is that patients maintain their natural neck motion as compared to a spinal fusion. (Spinal fusion is the current standard spine surgical treatment for degenerative disc disease.)  

A study that I participated in and co-authored, specifically evaluated the patient’s motion – comparing post-operative neck motion. Patients who received the Bryan Cervical Disc in cervical arthroplasty were compared to those that underwent a spinal fusion and anterior discectomy. 

In a prior blog, the recent FDA-approval of the Bryan Cervical Disc ™ was announced. One of the advantages of this device and cervical arthroplasty, as a spine surgical treatment for degenerative disc disease, is that patients can return to work and their normal activities in a relatively short period of time. Generally, this time period is quicker when compared to a spinal fusion – which is the current standard spine surgical treatment to this newer procedure and technology. At this time, spinal fusion is the standard surgical treatment.

A study recently published in Neurosurgery, concluded that patients that underwent cervical arthroplasty returned to work on average about three months sooner than those patients that underwent a spinal fusion and cervical discectomy. The patients who received the cervical artificial disc returned to work in a median time frame of 101 days following their spine surgery (cervical arthroplasty) as compared to 222 days in the group that underwent the spinal fusion and cervical discectomy.  

This blog entry will highlight Rapp Medical Systems Inc. | Medtronic Spinal & Biologics, a silver sponsor of Back Talk. Back Talk is the continuing medical education program that Indiana Spine Group is sponsoring for primary care physicians and practitioners. 
 

Rapp Medical Systems Inc. is a local medical product distributorship representing Medtronic Spinal and Biologics. Working with physicians, their mission is to provide superior products and service which will enable our physician partners to provide the highest level of patient care possible.

Medtronic Spinal and Biologics, is a division of Medtronic which focuses on spinal and  musculoskeletal therapies. Their key product areas include:

• Minimal Access Spine Technologies (MAST™) for treating painful conditions of the spine, such as degenerative disc disease.
• Fusion systems¹ that correct and stabilize abnormal spine curves.
• Artificial cervical discs² to replace damaged or degenerated discs in the neck. Our latest disc is made of surgical-grade stainless steel and allows motion so patients can go back to doing everyday activities they love.
• Infuse^® Bone Graft,³ a biologic that stimulates the body to regrow bone and is used to treat certain spinal, tibial, and maxillofacial conditions. Infuse Bone Graft eliminates the need to harvest bone from another area of the patient's body, thus eliminating an additional, often painful, surgery.

For more information, visit Medtronic Spinal and Biologics and for consumer education information visit their patient education site.