Neurosurgical Spine Evaluation - Chris Heller, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Chris Heller. Dr. Heller is a neurosurgeon. He did his medical school training at the Oregon Health Sciences University. From there he completed a neurosurgical residency at the University of Southern California. Today, Dr. Heller practices neurosurgery at the Huntington Memorial Hospital in Pasadena, California. Good morning, Dr. Heller.

Dr. Heller: Good morning.

Dr. Sechrest: Dr. Heller, what I would like to talk about is your approach to neurosurgical evaluation and treatment of spine pain. So, we’re really talking about something that happens in neurosurgery office every day, and that is, a patient comes who’s been either referred there by their primary care physician or maybe has just called up and made an appointment, and they either have back pain or neck pain, something that you and I see on a daily basis. I’d be interested in understanding how you approach those patients, and we’re going to talk a little bit about how you evaluate the patient, how you make treatment decisions, and then, in some ways, what your treatment concepts are for both back and neck pain, both conservative and surgical. So start out by telling me a little bit about when that patient shows up in your office, what’s the first thing you do?

Dr. Heller: Well, first of all, I have patients meet me in my office rather than an exam room, and I think that’s very important. I think it’s important that I meet somebody when they’re fully clothed and not in the open back gown. More than just the personal aspect of that, but also I think there is a lot to be learned from the history, from asking questions, really getting to know the person, not so much just in terms of the symptoms – where it hurts and when it started – but also I need to know what kind of job they do. I need to know what their interests are, and all of that goes into formulating a plan that’s individual for each person, and I find that in a much more comfortable environment, in nice chairs in my office, before we ever look at imaging pictures or do a physical exam.

Dr. Sechrest: I think that’s a wonderful point, because it goes back to one of the giants of medicine, William Osler, said, and one of his most famous quotes was that he felt it was ‘better to know the patient with the disease than the disease that the patient has’. I think that says something that even today, even in a specialty such as neurosurgery, it’s still so critical that we know something about the patient in order to actually treat that patient effectively. So, I’m glad to hear you say that, especially from a neurosurgeon.

Dr. Heller: No, I absolutely believe in that, and, some patients, I think, look at me funny when I’m asking them where they live. What kind of work do they do, or did they do before they retired. What are their hobbies – are they golf? It all comes in to play when you start to formulate a plan for how to deal with this particular problem.

Dr. Sechrest: Now, in terms of getting down to the specific reasons they’re there, the history you mentioned is very important, and I think that we, as physicians, you know, the party line amongst physicians is that the diagnosis is made 85% of the time based on the history, and I think patients sometimes think that all we do is tap on reflexes and run pinwheels down their arms and look at MRI scans – and sometimes I think they just think we look at MRI scans.

Dr. Heller: Right.

Dr. Sechrest: But I do think that we typically know after we’ve talked to the patient, or have a very good idea, of a differential diagnosis and the things that we’re going to try to either confirm or rule out in terms of what’s wrong with them. So I’d be interested in your history that you take with the patient, and what are the most key points that you try to bring out whether this patient has back pain or neck pain.

Dr. Heller: Yeah, whether it’s back or neck pain, there are a lot of very similar questions. It’s the timing of the pain. Has this been something that we’ve been dealing with on and off for 15 years? Or is this just since you lifted a heavy TV a week ago? There are inciting factors like that. Has there been any sort of car accident or fall down the stairs or is this just something that gradually came on? It’s important to know what kinds of things make the pain better. Is it something you’re waking up with in the morning or is it just after a hard day of work? What makes the pain worse? Is it sitting or standing? Is it lying flat? Certain things that people tell me, whether their pain gets better leaning forward or it gets better leaning back, really goes a long way towards helping me pinpoint, in my mind, where the pain’s coming from before we ever start doing a physical exam or looking at pictures.

Dr. Sechrest: Are there any things that would particularly cause you alarm? For example, if you’re asking questions and certain responses that a patient would give you, are there certain things in your repertoire that you would immediately sort of ramp up, your ears would perk up, and you would say, “Uh oh, I’ve got a problem here. I’m going to really go down this path and try to figure out what’s going on.”

Dr. Heller: While it’s not necessarily an emergency, worrisome things like loss of muscle strength, and, when you’re dealing with pain in the neck or back, oftentimes you’re also dealing with compression of nervous structures, the spinal nerves, or the spinal cord. Any time somebody starts talking to me about weakness in a hand or a foot or an arm and a leg and difficulty grabbing their toothbrush or holding on to their coffee cup. Those things kind of make my ears perk up. You’ve got to make sure you’re dealing with not just some arthritis in the back and there may be something serious going on with the nerves which may need to be dealt with sooner than later.

Dr. Sechrest: Yeah, I think we’re all more attuned, even orthopaedic surgeons, are more attuned to those nerve related symptoms that we’re hearing about. When a patient is telling us they’re having progressive weakness, as you’ve just described, progressive numbness, problems with walking, imbalances and that sort of stuff. I think we all put that in a different category, we’re a little bit more ready to do more on the physical examination and much more, in terms of imaging, to prove that we don’t have a significant problem that might get worse. I think the key, as you’ve mentioned, is anything that affects the neurological structures. If it’s just the disc, if it’s just the muscles, if it’s just the joints causing pain, that probably is something that’s not going to send up a lot of red flags.

Dr. Heller: Right, and it’s not that those things can’t cause significant pain that keeps people from doing what they need to do, in terms of disc problems and joint problems. But, you’re right, we always get excited about nerve sounding problems because those can tend to be more irreversible if they’re not dealt with in a timely fashion than bone and joint problems.

Dr. Sechrest: Yeah, I would agree, and I think that is the key point is that we’re really speeding up the process to try to prevent permanent damage, whereas most things with the discs, the arthritis, the muscles, aren’t causing permanent damage. We’ve got some time to try some conservative measures maybe. We’ve got some time to see if they get better, but the key issue is that they’re probably not causing permanent damage and we’re a little more lenient with those.

Dr. Heller: Right.

Dr. Sechrest: Now, once you’ve made this decision, and you move on to a physical examination, what you are you looking for in a patient with back and neck pain? What are the key elements that you’re focusing on with your physical examination?

Dr. Heller: The patient’s motor strength, of course, is very important. Even if somebody’s not specifically complaining about weakness in a muscle somewhere, it still needs to be checked out. There may be subtle weakness that they don’t even realize. So I definitely test motor strength in the arms and the legs. Sensation, as you mentioned, to both a sharp object or the pinwheel, and then soft touching, even vibration. It’s often difficult patients will find to quantify or qualify if there’s a decrease in sensation. They may complain of some numbness but when it really comes down to, “is this sharper here or is that sharper there?”, patients should not be surprised that it’s very difficult for people to identify that and it’s not them, it’s pretty much everybody. But the sensory exam is very important because, much like the motor function of the arms and legs, the sensation is distributed based on the nerve that could be involved to a certain part of the arm or the leg. So clues in terms of where the problem might be coming from, you know, can really be found in the sensory or motor exam; and then beyond that, it’s the old reflex hammer to the knee. It’s kind of a doctor cliché, but it’s very important for us because certainly when there are issues with the spinal nerves, it affects reflexes and sometimes earlier than anything else.

Dr. Sechrest: It’s interesting, too, I think you said that you pay perfect attention in the history when people start talking about functional things like they can’t hold their coffee cup, they can’t hold their toothbrush, and I think that goes back to the physical exam; and you mentioned that it’s very difficult sometimes to tell. I always pay a lot of attention when patients tell me that they have tingling or they have something even if I can’t reproduce it. I think that patients notice those things before we, as physicians, can actually see it on the physical exam, and sometimes that’s confusing to patients, but things like gait. Patients who tell you, “well, this is what’s happening and it’s just not right”, that’s important, and I might not be able to reproduce it on the physical exam, but I pay very close attention to that when they tell me that.

Dr. Heller: Right. There’s a whole lot of things, things like gait disturbance, people who are wobbly when they walk. We test things like the sensation in their feet, and if you’ve ever been to the doctor for this sort of problem, of course, the doctor will move your toe up and down. That’s a certain kind of sensation that allows you to tell where you are in space, and it’s important for us to look at all those things because, even though you may have arthritis or a bulging disc in your back or you may even have a lot of abnormalities on your MRI, it may also be some other reason why you’re having a problem walking. That’s partly our job, my job as a neurosurgeon or an orthopaedic spine surgeon, in addition to your primary care doctor or a neurologist, is to make sure that we’re treating what we think we’re treating. So it really is important to test everything, even if you’ve got neck pain, why am I testing reflexes in your ankle. Well, it’s all related.

Dr. Sechrest: Yeah, I agree. I think we’ll move on to another area that is sometimes confusing to patients, and that is the imaging that we do as part of our evaluation for neck and back pain. I guess, the first thing I would ask you is, what’s your favorite test? When you get done with a physical exam a lot of patients have the notion that we just always order an MRI scan as the next test, and that’s going to tell us everything we know. How do you approach imaging when you’re dealing with a back and a neck patient?

Dr. Heller: You’re absolutely right. That’s sort of the reputation that we’ve garnered for ourselves is we get everything off the MRI, and in fairness to that study it does give us a lot of information. MRI as opposed to a CT scan or a plain x-ray tells us a lot about the soft tissues and the nerves and the spinal cord and the ligaments and the joints that plain x-ray or CAT scan doesn’t show. Now, that being said, unfortunately it’s the exception to the rule that people come to my office with plain x-rays, just standard x-rays in the neck and the back, but they are quite helpful. They give a lot of information about the condition of the joints, and the disc spaces, and the overall alignment of the spine. You know a lot of problems that people run into with having, I guess what I would call, suboptimal outcomes in terms of pain relief from spine surgery has a lot to do with the overall alignment of the spine. Not whether the fusion took or whether the screws are in the right place, and that’s sort of a concept that I think is becoming much more popular. When I was in residency we had a visiting professor who spent an entire lecture about, that on all of his patients he gets a standing scoliosis style x-ray, which is an x-ray from basically the top of the head down to the tailbone to look at the alignment of the entire spine, not just the lumbar spine. So, the curvatures all have to be evaluated and the overall condition of the spine.

Dr. Sechrest: It’s interesting, because I think we’ve all had the experience of having physical therapists, osteopathic physicians, even chiropractors, talk about this whole spinal alignment, and I think in western medicine, and especially in allopathic medicine – the type that we do – we’ve tended to become reductionistic and focus on that one disc that we see that’s an abnormality on the MRI scan; and I think we’re changing, I think we’re beginning to understand some of these concepts that the physical therapists, and the osteopaths, and even the chiropractic physicians have tried to bring out, and that is this balance with the spine. It’s a challenge, and I think that it’s amazing to me how many problems in the spine do arise from this imbalance; and I don’t think you can necessarily fix them. You may have to do that surgery on that one disc to get everything fixed, but I don’t think you can just do that and expect all the problems to go away.

Dr. Heller: Right. If there’s a specific problem in the lower lumbar spine that just stands out on MRI and you fix that and, it’s a kind of an operation where you fuse somebody at that level, but you fuse them in what was already a suboptimal position for their spine. Like I said, it goes all the way from the top of the spine to even the pelvis. There’s an angulation of the pelvis that has to do with the spine. I’ll admit, especially as neurosurgeons, we’re not quite as in tune with as our orthopaedic counterparts, and we’re just going to have to get better at looking at that.

Dr. Sechrest: I would agree. I think we all do. I think even the orthopaedists aren’t that good at it. I think we’ve tended to sort of focus on individual components and thinking that that’s going to solve the problem, and, as an orthopaedic surgeon, I typically rely on people like the physical therapists that really understand this far better than I do, and try to help with an understanding of what the other parts of the spine are doing and what we need to do for those. Let’s talk about some specific tests, because I think that patients always want to know what test is best. You mentioned x-rays. We’ve mentioned MRI scan which, as you said, most patients show up in our office and they’ve already had an MRI scan. So we’re usually sitting down with the patient and saying what the MRI can tell us and what it can’t tell us. There are some more specialized tests that you and I may order. One is a myelogram, which is an older test, sometimes combined with a CT scan, and, I would say almost always combined with a CT scan, in this day and age. How do you find utilization of the MRI scan versus a CT myelogram in neurosurgical practice?

Dr. Heller: I find CT myelogram to actually give some of the best pictures of the spine. Now it has become outdated as MRI replaced it because a CT myelogram involves a lumbar puncture, so a needle going into the fluid space at the base of the lumbar spine and injecting contrast into the fluid. That’s the only way you can see it on a CAT scan. So being an invasive procedure, it tends to not be the first imaging study of choice. Typically I only get myelograms these days on people who can’t have an MRI scan. You know, they have a pacemaker or some other metallic device that doesn’t allow MRI, but when I do have to get a myelogram, I’m very pleased with the pictures. It tends to get very good detail. So you would typically get an MRI scan first, and then if necessary for surgical planning or you couldn’t get an MRI scan, you would move to a CT myelogram.

Dr. Heller: Exactly. I say the myelogram is so great, but the MRI still has wonderful pictures. It’s not that I’m avoiding doing a myelogram because of the lumbar puncture. You get great information from an MRI, but a myelogram, even though it’s a “dated” procedure, is still valuable in certain circumstances.

Dr. Sechrest: I think there are a couple of other tests that we probably ought to just cover to be complete. One is the electrical test that we sometimes order, and I think it’s sometimes confusing to patients, but EMGs, nerve conduction velocities, I mean, the body is just a big wiring diagram to some degree just like your car or any other electrical appliance.

Dr. Heller: Right.

Dr. Sechrest: And that test can sometimes can really help us pinpoint which nerve’s affected by how it’s affecting the muscles. I don’t know how much you use that test, but I think we find it fairly useful.

Dr. Heller: Yeah, I tend to use it quite a bit. I think the issue where EMG and nerve conduction studies comes into the play is that MRIs, they’ll tell you where there’s a bulging disc or a narrowed nerve outlet, or something like that, but they don’t tell you what’s causing the pain, and that’s the real trick when it comes to neck pain or back pain is what’s causing the pain, because of several different things – the joints, the discs, the nerves, lots of things can be causing the pain, and you’ll find many patients who have a horrible looking MRI but don’t have any pain, and then folks that have horrible burning pain in their arms and their hands, and their MRI looks great. Those are the extreme circumstances, but it must make you always think that just because I see something on this MRI, doesn’t necessarily mean that that’s causing the pain, and that’s where a study like an EMG and nerve conduction study comes in because it tests the electrical impulses coming from the spinal cord down to the muscles, and then impulses from sensation going back to the spinal cord. So it can really help us to pinpoint is this a problem with the nerve in the neck? Is this a problem with the nerve in the hand like carpal tunnel syndrome? And that really is an added bit of diagnostic information to help us pinpoint where the problem is because that’s the first big hurdle is what are we even trying to fix here.

Dr. Sechrest: You know, I think one other that this leads to, and that is, not all problems that show up in our office are coming from the spine itself. Or even the nervous system.

Dr. Heller: Right.

Dr. Sechrest: So a lot of times I think that patients wonder why we’re saying, “well, we’d like to get some of a test on your abdomen”, for example, or something to rule out other problems. One thing that comes to mind are lab tests. A lot of the problems we see in the spine can be coming from arthritis, and it’s not just the wear and tear arthritis, but it’s arthritis that involves other joints - rheumatoid arthritis, ankylosing spondylitis – so I think that we’re pretty quick on that first visit, if there’s any indication that there’s a systemic illness to begin to look at some other things that may not have anything to do with the spine. And sometimes that confuses patients because they think they’re there because somebody’s already decided they had a spine problem.

Dr. Heller: Right, and that’s why people come to see us is to see if they need an operation. That’s a specific question that I’m there to answer. Is there kind of operation or something I can do surgically to fix this problem? But, as you said, you do need to remind yourself to take a step back and make sure that you’re not missing something certainly that could be dealt with nonsurgically. I always tell patients that, in my mind at least, the best results are going to come from when basically I can predict what the imaging is going to show. So if I talk to somebody and I examine them and I say, “boy, I’ll bet they’ve got a bulging disc here”, and it matches the MRI, that’s typically when you have the best results. It’s when you have discordant results. So the imaging doesn’t match the symptoms and you’re kind of searching for something. That’s when you really have to be careful about embarking on anything surgical, in my opinion, because that’s when you’re probably missing another cause.

Dr. Sechrest: Yeah, I think all of us should realize that we may be neurosurgeons, we may be orthopaedic surgeons, but we’re also physicians, and a lot of these disease processes that present to us, they’re easy to miss and I think we have to take a step back like you said and look at the patient overall and say, “Why am I getting discordant results? Why is this not matching up? Is there something I’m missing? Is there some other disease process going on that I’m not aware of?”

Dr. Heller: Right. More people than we’d like to admit have had a disc taken out in their neck when they had carpal tunnel syndrome and that’s something you absolutely have to avoid.

Dr. Sechrest: Yeah, I think that’s true. Let’s talk a little bit about treatment. As you move towards treatment, you’ve done a good history, you’ve done a good physical exam, you’ve done what you need to do at that point with imaging. How do you make decisions about treatment? When is it appropriate to treat this person conservatively, and when would you recommend that maybe now surgery is an option for you?

Dr. Heller: Well, it all has to do with an individual patient by patient situation. Some patients have an acute disc herniation and a debilitating radiculopathy, and it happened when they lifted up a heavy box 2 weeks ago, and there’s no reason to waste time with medications and injections and that sort of thing. That’s a rare circumstance, but it does happen. On the other hand, as in most situations, you need to do a little bit more investigating and sometimes the investigations involve other procedures even that aren’t surgical procedures in the operating room, and those include things like selective injections around the facet joints, the joints that hook one vertebral level to the other. Injections of steroid or anesthetic around nerve roots. These sorts of things are both potentially diagnostic and therapeutic. So, as I mentioned before, the back is a very complex system and to try to pinpoint where the so-called pain generator is, what’s causing this pain, sometimes these injections can not only make patients feel better, which is good for them in terms of therapeutics, but it helps me in terms of diagnosis because, if this joint is injected and that typical back pain that the patient has is gone, even if it’s for a couple hours or a week, that helps me to figure out that maybe that’s where it’s coming from.

Dr. Sechrest: Yeah, it’s interesting. I always sit patients down and try to explain to them this concept of the pain generator and most of them clearly understand what we’re talking about. At first, I think they come into our office and they think that, once they’ve had that MRI scan, we’re going to have the answer. It just pops up right there on the MRI scan. But once you really sit down with them and talk with them and say, “Here’s the problem. The problem is that every MRI scan I look at has abnormalities on it. That doesn’t mean that that’s was causing your pain.” Then it becomes this process of elimination. Sometimes I end up with 4 or 5 abnormalities. I need to test each one of those abnormalities to see if they hurt and that’s where the injections come in. These diagnostic injections that give us information and, at the same time, probably won’t cure the problem, but probably will help the situation if we hit the right spot. And it may take us 2 or 3 tries and sometimes that can get a little tedious for patients as we try to eliminate each one of those potential pain generators.

Dr. Heller: No, I agree. It can be frustrating, because it’s multiple trips, and especially in my case, I don’t do those injections. I employ an interventional radiologist to do those. But it does require multiple trips between offices and back and forth, and it got better for a couple of days and it now it’s worse again; but I think the most important thing in this entire discussion is that any time you contemplate a surgical procedure on the spine, everybody, myself and the patient, we have to absolutely sure that, a) we’ve done everything first that could be done otherwise; and that, b) we’re doing it for the right reason. And if it means several months even of diagnostic tests and therapy and injections to make sure that we’re doing the right thing, then I believe it’s critically important.

Dr. Sechrest: Well, let’s talk a little bit about that conservative aspect of the care. When you don’t think surgery is necessary and you want to treat a patient conservatively, you want to try a few things to see if they work, what things do you really focus on in terms of helping a patient who may have a back problem, a neck problem, back pain, neck pain; what things do you really on in terms of your treatment program and recommendations that you make to those patients while you’re trying to assess that?

Dr. Heller: The most important thing is that in the majority of cases of new back or neck pain, it’s going to resolve on its own in a certain amount of time. So, that’s not necessarily comforting to someone who’s really hurting at the moment, but to dive right in to surgery for something that 6 weeks later isn’t going to be bothering that person as much anymore is something we all need to remember. But I believe that physical therapy is very, very important. As I said, it’s a very complex system, the back, and a lot of that has to do with the range-of-motion of the spine, the joints, and the overall muscle tone, and muscle fitness of not only the muscles running up and down the back, but the abdominal muscles, the whole core trunk area, and it applies to the neck as well. I try to approach this as gingerly as possible, but in America, in 2008, a lot of our back and neck problems have to do with people being overweight as well. It’s something that certainly needs to be brought up because in a lot situations, especially with low back pain, a weight loss of 5-10% can make the problem go away, and that’s not only healthy for the patient, but it avoids a potential operation as well. So, things like that, what we label conservative care, things like physical therapy, and even I consider conservative care to also be starting an organized exercise program as well. Then there’s medical therapy as well in terms of anti-inflammatory medications and pain medications and that sort of thing.

Dr. Sechrest: Well, that’s a good point to move to, and that is medications. I know a lot of physicians really shun the use of pain medications, such as hydrocodone, morphine, Lortab, that sort of stuff. What’s your take on that? Do you think they have a role in the treatment of acute back pain or over a period of time?

Dr. Heller: I think episodes of acute back pain. So, an acute back spasm from some kind of incident, lifting a heavy object, I think they do have a role. I think short period of time, you know, 1-2 weeks tops on narcotic type pain medications. But then mixed in with muscle relaxing type medicines, and even sometimes a day or two of bed rest. There are strategies to be dealt with that. I think that long-term usage of narcotic pain medication can lead to trouble. You know, tolerance and addiction for the patient, but it’s every time the patient goes to refill one of those medications, there’s just that feeling when you’re at the pharmacy or the doctor’s office that you’re being labeled a drug-seeker and that sort of thing. For a lot of reasons, I think it’s best to try to avoid that as much as possible.

Dr. Sechrest: How do you begin to make the decision as conservative care is failing, and we need to move on towards looking at surgical options. In your practice, what are the sort of things that you use to make that decision for patients?

Dr. Heller: Well, first and foremost, it’s as I mentioned before, the concordance of data. Everything, the imaging data, what I’m finding on physical exam, and the patient’s symptoms really have to match up, and I think if you already are in that situation and you’re pursuing conservative measures and after several weeks or several months we’re not just making any progress, then you have to start sitting down talking about surgical options. It’s not always just one procedure or two procedures, there are multiple options. I think some patients may get impatient, if you will, saying, “You know, I did therapy before and it doesn’t work” , or, “I did this before, it doesn’t work”. I really, really think that it’s important if we ever embark on a surgical procedure, as I mentioned, that we all know that we did everything. Because even though I wouldn’t recommend a procedure to someone that I didn’t think it was indicated, or that I thought was unsafe, even the best surgical procedure can have a bad outcome, and, God forbid, if we ever end up in that situation where somebody doesn’t get better from surgery, or gets worse after surgery, I think everybody has to feel that we exhausted all opportunities before we get to that point.

Dr. Sechrest: Yeah, I would agree, and I think in our society today there is this notion that somehow the technology of medicine has progressed to a point where we have the answer and somehow if we’re not offering that patient an operation we’re somehow keeping it from them, and I don’t think that’s correct. I think that we very rarely have the answer. We have something that we can offer that has a statistical chance of success and sometimes they don’t understand what those statistics mean. So, yeah, I think taking that conservative approach and really saying, “you know, if you don’t have anything that drives me to say you’re better off today without a doubt having surgery; you’re getting progressive weakness, you’re having some sort of a nerve-related problem that is problem causing permanent damage and if you don’t fix it today, then it’s going to be worse tomorrow and worse the next day”, then I think that all patients need to really, really look at whether they’re better off having an operation or not. Most of the operations we’re offering them, they’re going to work just as well 6 weeks from now as they are today.

Dr. Heller: Absolutely.

Dr. Sechrest: So, I don’t think there’s anything lost usually for most of the stuff we do.

Dr. Heller: Yeah, and what patients need to realize is that operating on the spine, whether it’s in the neck or the back, for pain, is not always as successful as we’d like it to be. Operations for nerve entrapment syndrome, bulging discs, burning pain in the hand or the arm or the leg, those tend to be more successful in terms of relieving the pain. Operating on the back for back pain, while it’s successful in some folks, it’s not as successful as the other types of operations. So those are the ones where it almost has to be that we get to the point where it’s such a debilitating pain, and I believe there’s some reasonable explanation for it based on the whole picture of the patient; but there’s something I can approach surgically that has a good chance of fixing it. But I think those two things have to be together to embark on an operation for back pain and then patients have to realize that if it’s 60-70%, that means that 30-40% of the people aren’t going to get better from that. But it has to reach this critical tipping point where the patient is so affected by this debilitating pain that we’re willing to take that leap and say I’m going to take this risk of going through an operation and having it not work.

Dr. Sechrest: Yeah, I would agree, and I think expectations, as you say, have to be clear on both sides.

Dr. Heller: I’m sorry to interrupt, I constantly tell patients that they need to have realistic expectations. They’re never going to feel like they were when they were 18 again. The goal is to make the pain manageable frankly. If it goes away completely, great. That’s rarely the case. Somebody who has a spine issue that has gotten them into my office in the first place, is probably never going to get pain-free again, in terms of back pain. Like I said, radicular pain, the symptoms in the arms and legs, that can often be taken care of completely. But oftentimes, somebody who has low back pain, neck pain, it’s tricky to make that go completely away. It happens, but it’s tricky.

Dr. Sechrest: I think if I could summarize what we’ve just discussed, and see if you agree with me. There are very few reasons that a patient would walk into your office or my office, and we would tell them, “you have to have an operation tomorrow”, very few. There are a few. I guess, first of all, let’s define those. What are those things that you and I would say, “you’re better off with an operation today”.

Dr. Heller: Well, it happened to me 2 weeks ago. I had a patient come in with a condition called myelopathy, which is an indication of injury to the spinal cord and the neck. The patient, over a very short period of time, over a 4-6 week period of time developed progressive numbness in his hands and his arms, and then was having trouble walking, was having gait instability, and on exam had abnormal reflexes and decreased motor strength. That, to me, is something that needs to be dealt with right away, and I think from the first time I saw him in my office, he was in surgery less than a week later, 4 or 6 days later. So, those are things, when it’s progressive over a short period of time, and, as we mentioned before, things that are potentially irreversible in terms of neurologic deficit, those are things that are going to go to surgery sooner than later. There are very, very few things that, well, I can’t hardly think of anything that would get admitted directly from my office and taken emergently to surgery. But most things, not only can be dealt with over a longer period of time, but I think ought to be dealt with. So we really know, we get into the whole situation, and know exactly what we’re dealing with.

Dr. Sechrest: Well, I think that’s the key point, and that is, probably if I could paraphrase it, I had a guest that put something this way: Once you make this decision you can’t take it back. So anything that you can’t take back, you need to make sure that that’s the right decision, and if it takes a few months, in the big scheme of things, that’ s probably not a long time.

Dr. Heller: We’ve all unfortunately, seen patients who’ve had multiple back operations. Sometimes you’ll hear people say, “Well, if they’ve had 5 spine operations, they were all a good idea except for the first one”; and that’s the thing we have to avoid and making sure that we make the right decision the first time and not start this cascade of having to try to fix the original mistake.

Dr. Sechrest: Well, I think this is an excellent window into the evaluation of spine problems, neck and back problems. Any advice you would have for patients that are faced with making this decision who have maybe been referred to a neurosurgeon, referred to an orthopaedic spine surgeon, because of back and neck pain. What would you encourage to ask that surgeon on that first visit?

Dr. Heller: Well, I would encourage people to make sure that they have a very clear idea of what to expect. As we said before, proper expectations are important and you get that information from the surgeon that you’re talking to. People need to know not only what to expect when things go perfectly, but what to potentially expect if things go wrong, and I think just being in that mindset so you’re not surprised by something like that makes it a lot easier to deal with if you are in the percentage of people that that happens to. If you have a 5% risk of a bad complication, if it happens to you it’s a 100%. So you have to know really what you’re getting in to and then ask yourself are those things that could potentially happen, even though it’s rare, is that a risk I’m willing to take because this neck pain or this back pain that I’m dealing with is affecting me to that degree.

Dr. Sechrest: I think that’s excellent information. I think that’s excellent advice. I do think that the one take-home message from our discussion is don’t rush it. I mean unless your surgeon is telling you, and it makes sense, that this is a problem that’s going to get worse tomorrow or the next day, don’t rush it. Take a very conservative approach and make sure that the choices that you’re making have to be made today and you have to move forward.

Dr. Heller: I couldn’t agree more. Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you’re an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you’ll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.