Lumbar Spine Degeneration - Justin Paquette, MD

Sechrest: Hello, I am Dr. Randale Sechrest your host for eOrthopodTV. Today I have with me as my guest Dr. Justin Paquette. Dr. Paquette is a neurosurgeon who practices complex spine surgery in Los Angeles, CA. Dr. Paquette did his medical training at Albany Medical College. He then went on to complete a residency in neurosurgery at the Harvard Tufts Combined Program in Boston, MA. From there he completed a fellowship in complex spine surgery in Los Angeles at Cedar Sinai. Good afternoon Dr. Paquette.

Paquette: Good afternoon.

Sechrest: Today what I would like to discuss is a fairly common condition in the elderly population. As people age we see all types of spinal deformities and what I would like to talk about is the natural history of spinal degeneration and what that can lead to in the lumbar spine. So tell us a little bit about the whole process of degeneration of the lumbar spine and the different problems that one encounters as these problems present themselves as we age.

Paquette: Sure. Well, this is really is a very important discussion to have because degenerative changes in the spine basically are a problem for the elderly. Anybody from the age of 50 years on could have significant degenerative problems. In our society __????__ is the fastest growing group of individuals are those that are going to be 50-60 years older and so therefore we are going to be seeing much more individuals with these types of problems and we are going to have to figure out what are the best ways to diagnose and to manage them. As surgeons, we throw around many different types of words. We throw around things such as spinal arthritis, degenerative disc disease, spondyloarthritis, spinal stenosis, osteoarthritis, etc. Essentially all of these words come down to mean two things, wear and tear. Wear and tear of the spine. As we age as we get older, things start to break down. Our body was not meant or designed to last for hundreds of years and so sooner or later in some individuals, later the body starts to break down. In one of those things that goes quickly are the joints. Now, we all know and are familiar with problems with hip joints degenerating or knee joints degenerating, finger joints degenerating and all it is, is that you have got two bones that come together with nice smooth cartilage between it that keep a nice smooth running joint. If there is any tears, rips or degeneration in that cartilage now the joint is no longer functioning well and there can be bone grinding on bone and that joint eventually goes on to fuse, an auto fusion and that is the body's response to that kind of pain. The same thing goes on in the back. We start to notice the early signs of degeneration in individuals in their 20s, and what we see is that in the intervertebral discs which help to link those bones in the spine harmoniously together, those discs which when we are young are very hydrated and full of water, allowing the discs to work as a good shock absorber. Those discs start to dry out. And as those discs dry out, they can cause little bulges or cracks, they can cause herniated discs of which you have all heard of, they could also cause loss of disc space height with a vertebrae collapsed down on other vertebrae which can pinch nerve or cause back pain, there also can be instability in the bones that used to be locked perfectly together by the disc and as that instability worsens, that can cause lots of pain, it can cause a situation called the spondylolisthesis. Now, all of these things are going on in everybody however, if you take 100 people off the street, look at their spines and you see these situations, only 10% maybe are symptomatic. So the vast majority of people who have these things going on are actually not being bothered by them. The question is, how do you determine who is having pain, and that is when you have to combine the clinical situation, the clinical exam and the radiologist's findings together to get the best picture. As we were saying, initially the discs start to wear out, the joints that are in the back of the spine which are linked together with the discs could also wear out the same time. These joints are called the facet joints, and some people even have injections into those joints, but the facet joints as they are linked to the discs degenerate at the same time. They can also be a significant cause of back pain as time goes on. Now the more advanced stages of degenerative changes in the spine can actually lead to an imbalance of the spine. Now a normal spine with good discs, good joints, everything is well put together, the spine will be, even though it is made of curves, links the head to the pelvis in a perfect balance looking from the front and looking from the side. This is probably the most essential concept to keep in mind when we are discussing spinal degenerative issues. If somebody gets out of balance, this can be an extremely painful situation over time, because what happens is the body recognizes when we are out of balance. If there is a curve in the skeleton, or scoliosis, the body does not want that and so constantly the muscles are pulling and firing to try to pull the body back into balance. Unfortunately, ultimately it is a battle we cannot win. Our muscles become fatigued and it gives the muscles spasms, we develop chronic fatigue and chronic pain syndrome.

Sechrest: Now Dr. Paquette we have covered a lot of ground, I want to go back and for the listener sort of define some of these concepts. One is we talked a little bit about degeneration and how it affects the intervertebral disc and how it affects the facet joints. Talk a little bit about the intervertebral disc. What is the intervertebral disc?

Paquette: The most basic way to describe an intervertebral disc would be basically a jelly donut. You know, the spine is made of multiple vertebrae which are all linked together harmoniously but in between those bones of are the intervertebral discs. The main function of which is to keep the spine together but also to act as a vertical shock absorber and a strain release for all the bones when they are moving together as we walk around on a daily basis. The outside of the discs is a a very strong hard cartilaginous material which basically adheres to the bone below and above and keeps it in the proper position. The interior of this disc is more of a kind of a crab meat consistency. It is much softer and that is what actually allows for the bending and then the return during those compressions of the disc itself. Now, there is quite a significant amount of both collagen but also water content in these discs when we are younger. As time goes on, and it is purely a function of time, the water content and the collagen content inside those discs starts to dissipate and as a result we see the discs narrowing down, they can start to crack on the side which is officially called an annular tear which can be very painful, but also you can get full disc herniations where parts of the inner part of the disc, that gooey crab material can sort of squirt out through the confines of the tough exterior, and those are the situations when a nerve can get pinched.

Sechrest: Now, you mentioned that everyone goes through this degenerative process.

Paquette: Uh, huh.

Sechrest: So we are going to see disc degeneration as a normal part of aging in most of the population.

Paquette: That is correct, and in fact if you took the next 100 people that came in, that were just walking across the street, and put them all in an MRI scanner, any age, any symptoms, whatever, 98% of those people would show some form of degenerative changes in one or more of the discs in their lumbar spine, but probably most of them won't by symptomatic.

Sechrest: Now lets go a little bit back to another structure called the facet joint. The facet joints that you describe are actually joints, like our knees, our wrists, our shoulder, the synovial joints that they are called.

Paquette: Correct.

Sechrest: How do they play into this whole process of degeneration in the lumbar spine.

Paquette: You can basically think of the joints in the spine as being a big tricycle. In the front we have the intervertebral disc which is basically the big wheel right in front and even though we call it a disc, it actually truly is a joint between two vertebra. Along with that joint in the front, there are two smaller joints in the back of the spine. These are called the facet joints. They also are connected together with cartilage and they allow it to bend twist move and slide during our daily motions until they allow an effortless full range of motion with bone gliding on bone without the pain that is involved in it. If the disc degenerates because those facet joints are intimately involved with that level motion, they also can degenerate and we have seen that the cartilage that was there can get broken down, bone spurs can occur and so pain can not only come from a bad disc but also the associated bad joints in the back.

Sechrest: So with degeneration we've got three problems, we've got two facet joints that are arthritic, similar to the way a knee or an ankle would wear out if it has been injured or just with arthritis and it looses it's cartilage. We've got the big joint in the front where the disc is which is now not doing it's job, it is moving more and it may even get to the point to where bone is rubbing on bone, the disc is completely degenerated and there is no longer anything that can provide any shock absorption.

Paquette: Correct.

Sechrest: So, what sort of problems does that cause in the spine? Are we just talking about pain, or does it cause other problems?

Paquette: Sure. It can cause a multitude of problems. Essentially what's going to happen because the body is smart, the body knows what's going on, the body recognizes that this joint which should be easily moving, not causing pain, is now changed. There is abnormal motion, the disc is collapsed, the joints are having bone spurs, the body recognizes that now this joint needs to be removed from the normal motion pattern of the spine. In fact, the decision is made to fuse that joint and so the body will then begin the process of auto fusion at that joint. The same kind of fusion we think of when we think of surgery, but the problem is that this can take up to ten years sometimes. It can be a painful process, but over time, bone will grow to bone, the disc itself will calcify, the joints will become locked in and at the end stage, those two vertebrae will now be completely and totally fused together.

Sechrest: Okay, so what you're describing here is the situation where we start out with a normal spine, has normal motion, and that segment between two vertebra which we sometimes refer to as a spinal segment moves very smoothly, the joints move smoothly, the disc is doing it's job, everything is happy. The next thing that happens is that the disc degenerates, you begin to get too much motion. That causes more pressure on the joints, more pain, may irritate the nerves, and then the body says this situation can't continues so it begins a process of actually going back the other direction to stiffen that. So we end up with a stiffer spine with less pain and that is the natural progression, assuming that everything goes the way nature intended, the spine becomes stable again and less painful.

Paquette: That is correct. The only problem with that, is that at the same time the body is not very specific as to where it produces this new bone or some of the arthritis that goes along with the stiffening of the spine, and that is why a lot of times, nerves that run right near these processes can get caught up in the problem and they can actually then get pinched off by new formed bone spurs or by excess ligament or other types of arthritic tissues that now in attempt to fuse the level, are also pinching off the associated spinal nerves.

Sechrest: Okay, so as this process continues, we get not only pain from the arthritic process, the mechanical pain that we sometimes talk about with just back pain, that just hurts in the back, we also get irritation on those nerves or actual pinching of the nerves so that they are actually compressed and may not function appropriately.

Paquette: Correct.

Sechrest: So let's go through some of the treatment options for some of these conditions. If I am a patient and I have too much motion because of degenerated disc, so I have got a disc that is degenerated, I have not facet joints that are degenerated in the back, how do you treat that?

Paquette: Basically, the first question that people want to ask when they come in is, do I have to have surgery? The way that I answer that question is, there is essentially only two situations under which we need to think about surgery first, because in all of the situations, I much prefer to do conservative approaches in the beginning. The first condition under which surgery should be thought of relatively early is if there is any presence of neurologic deficit, and by that I mean that the nerves that are at that area are being so badly pinched that there is now weakness in the feet, for example a foot drop or dragging a leg behind you when you are walking, if there is any kind of progressive and worsening numbness in the legs or if there is any kind of bowel and bladder problems. Those would be concerning red flag symptoms to me that would say we need to start thinking about surgically decompressing those nerves sooner. The other situation to consider surgery is when the pain and the dysfunction of the situation is so great that the patient's lifestyle, all of their activities, everything is completely affected by his pain. They have tried all of the conservative therapies and failed. At that point then surgery also becomes a good option.

Sechrest: So if I can paraphrase, we've got two situations. One, where you're starting to see the body not work right because nerves are involved and that's one indication that you would say, you know, surgery is probably a better option than just trying to treat this and allow this to continue. And then you've got the whole situation where maybe the nerves are working fine but the pain is uncontrollable in any other way other than stabilizing that segment. The patient can't wait out the situation until the spine becomes stiff enough that the pain decreases, which we would assume is going to happen with the natural progression of this disease process that we just talked about.

Paquette: Yeah, that's correct. Now any other situation that doesn't fall into those two stages, in other words, people do not have neurologic deficits and the pain is relatively controlled by other measures, then absolutely we want to maximize the conservative therapies first and there is a few different routes that we do. First of all it is going to be pain management and so that can include simple things like anti-inflammatories, muscle relaxers, narcotic medications and sometimes oral steroids, and all of these things can be very helpful particularly because we are dealing with processes of inflammation. So any medication that will help to reverse inflammation can be very good. There is also simple things just as ice which would help to anti-inflame that area and make the pain feel better. The most important thing for sure for all these patient's is going to be physical therapy. Aggressive active psychical therapy working particularly on strengthening the core muscles of the belly, the back, the upper legs, but also working on flexibility and range of motion which are sometimes significantly lost in people that have these types of back issues. And if you can increase the activity levels and the strength in the core muscles, that sometimes has a very significant affect in the patient's overall discomfort.

Sechrest: Let's move on to the end stages of this degenerative process. If a patient gets through these early stages where they are having mechanical pain, they don't have a ruptured disc, so they don't need anything done to decompress a nerve root or something like that and the degenerative process continues. What's the result of this imbalance that continues to progress in the lumbar spine?

Paquette: So as the degenerative process continues, there are a few different options. One of them is that nothing dramatically changes, it stabilizes, it gets worse a little over time but the patient's symptoms don't get dramatically different. That is one option. The second option is that things continue to get worse but they start to multiply on top of each other. And the problem is that as multiple discs start to wear out, as multiple facet joints start to wear out, the integrity of the spine can become significantly altered and what we start to see develop is a degenerative scoliosis. This isn't the kind of scoliosis you think of when you think of a kid that has a curved back. You started off with a straight back but what happens is that different joints start to develop different problems and the forces of gravity asymmetrically load those joints and the resulting curve starts to develop and start to wear down.

Sechrest: So let me sort of understand this better. The spine can be seen as five or six blocks stacked on top of each other, so what you're saying is when we start out in life normally unless we have some sort of congenital abnormality, those blocks are stacked in a straight line if I look at the patient from the front. If I look at the patient from the side there is a little bit of a curve which is normal and as we begin to see degeneration with the pads between those stacked blocks for example, they begin to tilt and I am assuming that the forces of gravity will tend to increase the pressure and that tilt will continue and the worse it gets, the more pressure there is trying to make it tilt more and it just continues to tilt.

Paquette: That's exactly correct. I mean, we have, the official term for it is a listhesis. You've heard of a spondylolisthesis where one bone slips in front of another bone but there is also lateral listhesis where instead of being perfectly linked in front of each other, one bone starts to slide off to the side and exactly as you described, the force of gravity now is shifted over and will now make this even worse and worse as time goes on. Not only is that very significantly painful, it can be debilitating sometimes as far as the back pain, but it also crushes those nerves that are associated at that level as well.

Sechrest: Okay, so we've got several different problems again, we've got a worsening of the mechanical pain because now we've got muscles trying to hold the spine and compensate for that abnormality, we've got bones that are no longer aligned and may be shifting in all sorts of directions with too much motion. That's causing mechanical pain in the back, perhaps arthritis in the joints and the discs and I think what you're saying is that as those bones begin to collapse even more, the openings where the nerves come out of the spine close even more. So now, we've got bone spurs, we've got collapsing vertebra and the nerves are at risk so that we are getting more nerve compression and nerve irritation and pain.

Paquette: The patient's will get worsening back pain and worsening leg pain.

Sechrest: And I think you referred to this disease process as degenerative scoliosis.

Paquette: Correct.

Sechrest: And scoliosis, as I think we have defined before, is a curve when you look at the person from the front it is a curve sideways and normally we don't have that curve.

Paquette: Correct.

Sechrest: How to you evaluate a patient who has degenerative scoliosis? What do you do in your office to try to determine whether that patient is going to need a surgical procedure?

Paquette: So when a person who has a diagnosis of degenerative scoliosis comes to my office, the first thing I will do is talk to them. And it is important to define very closely their exact history. Had they had injuries to the back before? Have they had surgery to the back before? And what particularly are their symptoms? Is it mostly back pain hurting them? Is it mostly leg pain hurting them? Do they have weakness? Do they have numbness? Do they have neck symptoms? All of these things will start me thinking in the back of my mind, what part of the spine is most significant and what part of the nerves or the spine itself are causing those individuals complaints. Once we have a good history, the next step is to get good radiology. And in general, you're definitely going to have to have at least a CT or a CAT scan or an MRI scan which allow you to look very specifically at all the bones of the spine, in all of the nerves of the spine as well to see exactly which ones are being compressed and in particular which way. Another particular film that I'll do always in the office for degenerative scoliosis are what are called 36x14 full length spine films. These are films that will show me the entire spine all in one x-ray. There's one shot from the front and one shot from the side. The whole reason to get these x-rays comes down to one word which is balance. Again, treating, diagnosing and helping degenerative scoliosis really all comes down to balance and what we'll often times see in individuals with degenerative scoliosis is not just a curve tilting somebody off either to the right or to the left, but more importantly they get tilted forwards. As the bones in the lumbar spine degenerate, instead of having a normal curve like this, what we call lordosis, a lo of times those discs and joints degenerate and the spine now starts to pitch forwards and causes what's called a flat back syndrome or a positive sagittal imbalance.

Sechrest: Now let's define that because this is an interesting point. We think of the scoliosis because we tend to look at people two dimensionally. We tend to look at them from the front or the back, or front or the side I would say. What you're saying is that it's not just the sideways curve but they've lost that normal curve so it's really a curve in two different directions that we are faced with. An imbalance in two directions.

Paquette: Absolutely correct. Yes.

Sechrest: Now one thing that patient's will commonly ask is will this situation get worse? I mean, the first thing they ask is, okay, I have degenerative scoliosis, what are our predictions as to whether it will get worse, is it doomed to get worse? Will some people stabilize and not get worse.

Paquette: Well, that's the ultimate question of all questions, and absolutely everybody asks that question. The reason for this problem to develop is because of time. Again, it's wear and tear, it's a degenerative process and we do expect that over time these things will get worse. It will get especially worse faster if the person is quite out of balance. In other words, if somebody is pitched very far forward or has a bit shift laterally on one of those vertebrae, now the forces or gravity are loading significantly asymmetrically and we do see a more rapid progression in the patient's change in the spine. However, that does not necessarily mean that the patient's symptoms will get worse. And the only way to follow that is just to see over time, to follow the x-rays closely and follow the patient's symptoms closely. Sometimes if you institute a very strong physical therapy program, good medication management, you can actually strengthen the muscles to the point where they're not having as much pain as they did. Maybe you could buy at least a few more years before having to do a major interventional surgery.

Sechrest: So it sounds to me like what the rule of thumb is, is that the worse it is, the more likely it is to get worse faster. So more imbalance leads to faster degeneration.

Paquette: Correct.

Sechrest: You mentioned the physical therapy and the compensation and the strengthening. Patient's are always asking if they can stop this process without surgery. And two things that come to mind, one is how much does something like Yoga, physical therapy, a good stretching and exercise program that tends to strengthen those muscles, how successful is that at slowing down the process and can it completely stop the process.

Paquette: I am a very big proponent of all those kinds of physical therapy programs whether it be Yoga, Pilate's, swimming, whatever it is to start to strengthen the core. The goal of that however is not to stop the degenerative process. That cannot be done, you know, until we discover the fountain of youth and turn back time, our bodies will always continue to age. However, the stronger we can make ourselves, the stronger the core muscles are, the more that we can compensate for a degenerative spine. And we do certainly know that with completely lack of tone in the muscles, things degenerate faster. So I personally believe that if you do make yourself very strong in the muscles, you can deal with the pain better, hopefully at least slow down the process. But with the realization in the back of our minds that we're never going to actually stop it.

Sechrest: Now, the other thing patient's commonly ask is about braces for this disease process. Do you find braces useful in trying to either treat the symptoms of degenerative scoliosis or arresting the progression of the degenerative scoliosis?

Paquette: In the terms of scoliosis and bracing, bracing has often been used for pediatric cases with very flexible spines in an attempt to halt the progression of the curve. We have to remember that adult degenerative scoliosis is a completely different situation. The use of bracing would be only useful if somebody has lots of back pain from imbalance and using a brace will help to kind of bolster the muscles and make you feel a little better. It will definitely, not in any way, slow down or change the degenerative process in the spine. It will do nothing for radiculopathy in the legs or pain in the legs and the concern about it is that somebody wears a brace all the time, it actually works against you in making the muscles weaker. Because that actually takes over some of the function of the muscles and you are not using as much as you would normally otherwise and so I will use it in certain cases, but I think in general, we realize that it is not going to change anything within the spine.

Sechrest: So let's move on to more aggressive treatment options for degenerative scoliosis. How do you make the decision, when is the right time for a patient to actually have surgery or consider surgery as a more likely successful option than putting surgery off and continuing to try to manage this problem.

Paquette: So again there is probably two major instances when in my discussions with my patient's we'll say we should consider a surgery as an option now. The first time again is with any type of neurologic deficits, bowel and bladder problems, weakness of the legs. These things are very serious and need to be addressed earlier with a surgical intervention. The other situation is when the pain and the dysfunction or the disfigurement from the deformity is so great that it is affecting the patient's lifestyle on a daily basis, we've tried all the conservative efforts and none of those have helped to control the situation, that's another good option and a good time to consider a surgical intervention.

Sechrest: Now let's talk a little bit about our options with surgical planning. When you've made the decision with the patient, that surgery is the best option. What happens at that point? What needs to be done to determine what type of surgery you are going to do?

Paquette: So when a patient comes to my office and we have now decided it is time to go down the surgical pathway, the first thing to do is I will get all of the studies, MRI scans, CAT scans, the x-rays and go over the whole anatomy and the pathology with the patient. It is very important that they understand exactly what's going on when I describe to them ultimately what we are going to do for it. So we look at all the problems and then we go from there. The surgery itself I break down into a couple of different goals. It's all done in the same day but there is a variety of things we need to accomplish to give a patient the best chance for improvement. The first step of the goal is to basically decompress all of the nerves and so we'll open the incision, go down to the spine and then bring in the operating microscope. At each level of the spine where nerves are being pinched, I'll then do some special surgery with a microdissection techniques and little tiny instruments to take all the pressure off those nerves to make sure that every single nerve is completely free. Once that part of the procedure is done, then I will proceed to the placement of the implantations which are the small screws that will go in to hold the spine in the proper position. These screws can be either titanium or sometimes steel and they are done using lots of x-rays. I use x-rays and what I am looking at to make sure that they go exactly where I want them to go. I also have a neurologist in the operating room, monitoring the function of those nerves as I am putting in the screws to make sure that there are no issues with the spinal nerves. Once all of the instrumentation is in, the next point is to make the spine as flexible as possible so that I can basically take the curves out, put it in the right position and then lock it down. There is a variety of things that can be done to mobilize the spine. In general, with adult deformity, the curves that have occurred are kind of fused in that position, the joints have degenerated, the discs have degenerated and now it is locked. As opposed to a pediatric spine which is still very flexible, the adult degenerative spine is locked and so a lot of work needs to be done to basically separate the spine and it makes if flexible. And what we'll often times do it I will take off all the joints of the back of the spine and loosen the whole thing up at each level by removing some of the bones, some of the ligaments, etc. which will then restore some of the side to side and up down mobility. Once that's done, I then take special rods which I bend and twist into the exact position that I want that person's spine to be in. Once I have done that, I then lock those rods into all the heads of the screws up and down the spine, the levels that we are using. I lock those in, I do some more bending and twisting inside to try to get the curves as straight as possible and to restore the balance, again balance being the key to the whole procedure. Then I take a bunch more x-rays, similar to what people would have had preoperatively, the big long scoliosis x-rays to look again at the overall balance, side to side and front to back. If I am happy with it then we are pretty much done, if I am not happy with it then I have to do a little more bending and twisting to get to the point that I am happy.

Sechrest: So it sounds like the steps just to paraphrase is first you want to make sure that all the nerves have no pressure on them. So all the nerves have as much breathing room, so to speak, as possible. Once that's done, you essentially want to take a spine that is crooked and put it back as close to the normal arrangement as possible, lock it with the metal screws and the metal rods, and then allow it to heal in that position. Is that pretty much it?

Paquette: Exactly. The hardware that goes in, the little screws and rods, essentially you can think of it as an internal brace. 'Cause once we make the spine flexible, it's very flexible, in other words it's actually so flexible that it's unstable. It would be unsafe to allow the spine to still be like this and so we bring them back to the position we want and we lock it solidly in position with the metal until the bone itself takes over and heals.

Sechrest: So you're not really counting on the metal after the bone heals and the fusion occurs.

Paquette: Correct.

Sechrest: So the metal struts, so to speak, are not necessarily what is holding that spine for the rest of the patient's life. You're counting on the healing to reestablish that new arrangement for the vertebra and then lock it down by healing again.

Paquette: That's absolutely right.

Sechrest: Do you ever take the hardware out?

Paquette: I almost never take the hardware out. If this is a successful fusion. Most people can't feel the hardware and so therefore complaints of pain I think are coming from other regions. Muscle spasms or things like that. I have never taken out hardware just because somebody thought they were being hurt by it. However, many patient's that are sent to me have had multiple prior surgeries in the past. Failed surgeries where something has not fused or things have broken. In order to fix those individual spines, I do have to take out all the old hardware than do more work and then put in new hardware of my own.

Sechrest: Now is there anything special that patient's need to do before this surgery? Is there anything they need to do to get ready for this surgery.

Paquette: There's a few things they can do to maximize their recovery from surgery. As active as they can be, as much as they can do with the physical therapy program to strengthen their muscles will help them be that much more ready to recover from surgery. Certainly people that are very deconditioned and have very poor muscle tone are going to have difficulty, you know, getting up and moving around after surgery, where those that are in shape have much better recovery periods. In addition to that and very importantly, people that are taking large, large, large amount of narcotics and pain medicines before surgery are the most difficult people to manage for postoperative pain, and the reason being is that the brain can only get so much pain meds. Once you've supersaturated the brain's ability to respond to medications and then you do surgery where there is more pain, it is very difficult to help to control that patients pain and so we try to use our pain medicine colleagues to bring that patient's pain intake as low as possible just before surgery to make it easier to take care of them afterwards.

Sechrest: And what should patient's expect after surgery? How long are you in the hospital after a surgery this big?

Paquette: So what I would quote as a general recovery process for one of these major surgeries, starting the day of surgery, the surgery itself can take anywhere from 6-12 hours depending upon how many levels are involved, how hard it is to do the surgery and how many surgeries they have done before. I send all my patients overnight just for observation reasons to the Intensive Care Unit to make sure that they're comfortable, watch the blood tests and things like this. Once they are stable from an ICU perspective, I tell them to expect at least 5-7 days in the hospital. That's with working with physical therapy and walking on the first operative day, advancing their diet and moving along. Sometimes I give individuals with very poor bone or osteoporosis a larger brace to wear, but most of my patient's I will just give a lumbar corset for comfort. Physical therapy will see the patient every day and they're very valuable to me in assessing their abilities to walk and get around. If they feel they are doing very well then a lot of times they will be discharged to go home if a family member's there or sometimes discharged to home with a home physical therapist to help out once in a while. If they are still having some difficulties walking, or if they are very deconditioned before surgery, sometimes we will use a short-term rehab stay to maximize their recovery process and that could be probably for a few weeks after surgery as well.

Sechrest: Now how long should I expect if I'm a patient who undergoes, let's just say three or four vertebra being fused together which is a relatively large surgery. How long does it take me to get well?

Paquette: On average, this is what I would say to that, for just a three level fusion you'd probably be out of the hospital in about three days. If you did not have severe pain, you could probably drive within a couple of weeks, noticing that you probably would have pretty significant muscle spasms in your back for the first few weeks of surgery, which is a normal occurrence. It's kind of like being kicked by a horse. You get Charlie horses in the back of your back. Those start to dissipate and soothe over the ensuing weeks but they can be present sometimes up to a month out. I see all my patient's one week after surgery just to make sure things are going right and then I see them back six weeks after surgery. A major turning point in the back pain is about six weeks time. The muscle spasms have gotten much better. The ability to get up and move around has become much better and ultimately at six weeks I will have that individual sent for an aggressive outpatient physical therapy. Some individuals get better much faster than that, some people take a bit longer. However around six weeks, people generally say, I'm really starting to feel a lot better. I'm much more mobile now, doing well. And so that's why at six weeks I get all of my patients, every single one into an aggressive physical therapy outpatient program and this is working specifically on core muscle strengthening, on flexibility, range of motion and basically getting them back to their normal activities. After a full six weeks of physical therapy, I basically have no restrictions on my patients. They can do anything they want to do.

Sechrest: And how long do you think patient's will continue to improve after this surgery? I mean, is this a year long process that they can expect to get better and better? Is it a two year process? When am I completely stable?

Paquette: I think that probably in general within the first year you're going to find their maximum improvement and usually much more before that. What I have noticed with patients is that within even the first week or two they notice that their feelings of instability and nerve pain have gotten dramatically better. And then things start to stabilize and get better at a much slower rate, and as the weeks and months go by they're noticing that they are able to walk further, they're able to stand up further, their whole body appearance is different but they're still having some muscle spasms etc. However, as time goes on in the months, you know, three months, six months, nine months, people just start to get dramatically better and I would say that almost invariably by a year at the latest people are feeling much better back to their normal situation.

Sechrest: And I am assuming you're encouraging those patient's to continue on some type of a physical exercise program where they continue to be as active and continue that strengthening process.

Paquette: Absolutely. The physical therapy course that I start for them shortly after surgery is not just a six week in time. This is meant to basically prepare them for the long-term care of their spinal health. It's extremely important, not only for their recovery, but again for preventing further problems down the line or at least lessening the kind of pain they might get. So I have all of the therapists give them a home program to work on every single day in addition to the physical therapy program.

Sechrest: Now let's talk about something that a lot of spine surgeons don't like to talk about and that is the complications. What do you as a spine surgeon worry about when you are doing this type of an operation for degenerative scoliosis?

Paquette: Sure. We obviously worry about many things during these types of situations and a lot of it comes from the fact that degenerative scoliosis patient's are not kids and kids have no medical problems. Whereas older people certainly do and the average patient that I operate on, who has adult degenerative scoliosis, the youngest is 50 and it ranges up to the 90s and so these individuals are obviously going to have other problems whether it be heart problems, blood problems, cancer problems, all of the things that are going on at the same time, osteoporosis and so all of those need to be managed and absolutely taken care of as best as possible before going in to surgery because certainly any of those things can lead to complications afterwards. With a respect specifically to the surgery, any time you cut a patient, there is a chance of an infection or bleeding. We try to do many things to minimize the infection rate and fortunately we see a very low one, but I would say that it is certainly much less than one percent in our patient's. Blood loss is an expected thing to recur during these cases. They're long cases with very big incisions. Many people lose one to even three liters of blood during the procedure. The fortunate thing is that we have these machines which can collect all the blood and give the blood back to the person during the surgery. However, usually in the first couple of days after surgery they require another transfusion just because the IV fluids kind of dilute out the situation. Other concerns that we specifically have to look at are injuries to the nerves or to the spinal cord and we do many things to try to minimize any of these things happening.
1. We operate with microscopes which give us excellent illumination and magnification in the areas that we are looking at.
2. We have very good tools and techniques these days which have advanced the outcomes and the safety and reliability of spine surgery.
3. I use lots of x-rays during the procedure and sometimes neuronavigation techniques which allow us to be very specific to where we put screws and where we are exactly in the field of the spine while we're there working.
4. We also use neurologists to monitor function of the nerves and the spinal cord while we're operating to make sure that we haven't done anything to affect those structures.

Sechrest: In your experience, how likely is it if a patient undergoes surgery for degenerative scoliosis that they will need a second operation or a third operation?

Paquette: Unfortunately I think that, that likelihood definitely exists, in fact, most of my patient's that come to be have already been operated on many times. Some of them have been fused in what's called flat back syndrome where they're pitched forwards like this, some of them have had failed fusions where the bone has never grown together exactly. Some of them had degeneration at other levels and had to have more and more fusions done and some of them have persistent pain. And the important thing is to decide why is that the case, and so when an individual comes to me like this, I'll get a whole battery of tests including certain MRIs, certain CT myelograms and other types of tests which will specifically show me, are there still persistent problems explaining that patient's pain. And I would have to say that in most cases we can identify something that is causing it. Either nerves are still being pinched despite the surgery, the fusion has failed or there is some broken hardware because of it or more importantly, maybe most importantly, is the patient's balance. You can have a successful fusion of the lumbar spine, but if the patient is balanced forwards, they're going to be in tremendous pain because they are always going to be fighting that to try to stand up straight and those individuals actually respond very well to redoing a major deformity case if you address the goal of balance. In other words, you basically take what their spine is now and bring the balance back to normal, you could actually do a wondrous thing for that patient in their pain level.

Sechrest: Um, tell me if you have any advice you would give to a patient who has degenerative scoliosis and is trying to decide whether or not surgery is an appropriate treatment option for them, how would you advise that patient?

Paquette: When a patient asks me to specifically advise them if they are or not a surgical candidate, my response to them is this, no one can tell you this. No one can tell you when you need to have surgery. The reason being is that is that they're the ones that are suffering the pain, they're the ones that are suffering the disability, they're the ones that are suffering the deformity. Now, some people may just want to sit on the couch all day long and watch TV. For them, it may not be necessary to improve their current situation, they may not need surgery. Another person may be very active, want to get along and their whole life is changed because of this deformity. Those people would obviously do very well with a surgery. And so I basically ask them what is it that you want out of life? What is it that bothers you now? If they have an obvious deformity that bothers them a lot, that's something that can be definitely helped with surgery. If it's the fact that they can't walk more than a block at a time and they used to walk miles, that's something that can definitely help with deformity surgery. And so you have to figure out exactly what it is the patient is suffering from and then the physician and the patient have to come together and decide what are the realistic goals of the surgery?

Sechrest: Well, thank you, I think that's good advice for anybody facing any type of surgery and especially something that is what we would consider elective surgery. Something that's not necessary, but something that the patient is trying to achieve a specific goal and need to have realistic expectations of what they're trying to achieve and whether that operation can really get them there.

Paquette: And one of the reasons why I personally like doing deformity surgery so much, and we do all kinds of surgery. You know, tiny little middle evasive surgeries, disc surgery etc. But what I have found is that deformity patient's usually are suffering so great that when you can get their body back into balance and help them feel better, they're probably some of the happiest patient's that I operate on.

Sechrest: Well, thanks, good advice. Thank you.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.