I started by choosing medical journals with a focus on orthopedics. The Journal of Bone and Joint Surgery, the Stone Clinic, and the Journal of Pediatric Orthopaedics are three such organizations, and their web sites are easy to use. The main flaw with all of these sites is that they are written for orthopedic specialists, so some of the articles are hard to understand. Edheads, on the other hand, is an interactive site with flash animations of hip and knee replacement surgeries. It is directed more toward the layman than the specialist, which makes it easy to follow but also gives it a childish air. Orthoseek.com and Swarm Interactive strike a nice balance between these two extremes. Orthoseek.com contains medical definitions in an easy to use format but does not overwhelm the reader with medical jargon. Swarm Interactive is a wonderful site with animated descriptions of many surgical procedures. It is designed for patient education, so the videos are simple enough to be easy to understand but detailed enough to provide a valuable learning experience. YourSurgery.com is another site that aims to educate patients getting ready to have surgery. Unlike Swarm Interactive, Yoursurgery.com is not a free service. To watch one video costs five dollars, and a year-long membership costs one hundred dollars. I am nevertheless including it on my linkroll because it looks like it could be an invaluable resource to any of my readers who do not mind paying for high-quality information. Last but not least is World Ortho (provider of the image above), a site whose navigation system alone won it high marks in my opinion. Possibly the most interesting piece of information on this site is a series of lecture notes from an Orthopedics class. It was very enriching for me to read them, and I hope my readers will find them equally stimulating.
3/29/08
Back to the Linkroll: Further Efforts to Increase the Value of my Blog
A few weeks ago, I decided to update my linkroll by trolling through the web in search of high quality sites to link to. I am continuing this charge with my newest post because I want my blog to become more than just a dead-end sink for my own writing. I want to provide links to other quality sites so that my readers will be able to use my blog as a multi-dimensional source of information. As with my previous post, I relied on the Webby Awards and the IMSA criteria to determine what sites were of a quality high enough to link to from my blog.
I started by choosing medical journals with a focus on orthopedics. The Journal of Bone and Joint Surgery, the Stone Clinic, and the Journal of Pediatric Orthopaedics are three such organizations, and their web sites are easy to use. The main flaw with all of these sites is that they are written for orthopedic specialists, so some of the articles are hard to understand. Edheads, on the other hand, is an interactive site with flash animations of hip and knee replacement surgeries. It is directed more toward the layman than the specialist, which makes it easy to follow but also gives it a childish air. Orthoseek.com and Swarm Interactive strike a nice balance between these two extremes. Orthoseek.com contains medical definitions in an easy to use format but does not overwhelm the reader with medical jargon. Swarm Interactive is a wonderful site with animated descriptions of many surgical procedures. It is designed for patient education, so the videos are simple enough to be easy to understand but detailed enough to provide a valuable learning experience. YourSurgery.com is another site that aims to educate patients getting ready to have surgery. Unlike Swarm Interactive, Yoursurgery.com is not a free service. To watch one video costs five dollars, and a year-long membership costs one hundred dollars. I am nevertheless including it on my linkroll because it looks like it could be an invaluable resource to any of my readers who do not mind paying for high-quality information. Last but not least is World Ortho (provider of the image above), a site whose navigation system alone won it high marks in my opinion. Possibly the most interesting piece of information on this site is a series of lecture notes from an Orthopedics class. It was very enriching for me to read them, and I hope my readers will find them equally stimulating.
I started by choosing medical journals with a focus on orthopedics. The Journal of Bone and Joint Surgery, the Stone Clinic, and the Journal of Pediatric Orthopaedics are three such organizations, and their web sites are easy to use. The main flaw with all of these sites is that they are written for orthopedic specialists, so some of the articles are hard to understand. Edheads, on the other hand, is an interactive site with flash animations of hip and knee replacement surgeries. It is directed more toward the layman than the specialist, which makes it easy to follow but also gives it a childish air. Orthoseek.com and Swarm Interactive strike a nice balance between these two extremes. Orthoseek.com contains medical definitions in an easy to use format but does not overwhelm the reader with medical jargon. Swarm Interactive is a wonderful site with animated descriptions of many surgical procedures. It is designed for patient education, so the videos are simple enough to be easy to understand but detailed enough to provide a valuable learning experience. YourSurgery.com is another site that aims to educate patients getting ready to have surgery. Unlike Swarm Interactive, Yoursurgery.com is not a free service. To watch one video costs five dollars, and a year-long membership costs one hundred dollars. I am nevertheless including it on my linkroll because it looks like it could be an invaluable resource to any of my readers who do not mind paying for high-quality information. Last but not least is World Ortho (provider of the image above), a site whose navigation system alone won it high marks in my opinion. Possibly the most interesting piece of information on this site is a series of lecture notes from an Orthopedics class. It was very enriching for me to read them, and I hope my readers will find them equally stimulating.
3/10/08
Total or Mini: Will a New Hip Replacement Technique Take Over?
As I mentioned I would in my previous post, this week I used my linkroll to find a topic on which to write. What I found was quite interesting. There is a new orthopedic procedure for hip replacement known as a mini, or minimally invasive hip replacement. This is an alternative to the standard total hip replacement. The intriguing thing about this new procedure is that the surgeons performing it claim to be able to create the same end result as a traditional open hip replacement without the long hospital stay associated with such an operation. I feel that this is simply not the case. While it is true that the recovery time is shorter for patients who undergo the mini hip replacement, there are greater risks for long-term complications that negate any initial benefits of the less-invasive surgery.
The total hip replacement procedure is one of the oldest and most successful orthopedic operations performed today. No other joint can be replaced as easily or completely as the hip. The procedure is performed exactly the way it sounds.
The entire hip joint is removed from its socket and sawn off of the top of the femur. An artificial prosthesis (image to the right) is then inserted into the core of the femur and locked into place with methyl methacrylate, a bony cement. Younger or more physically demanding patients can chose a cementless prosthesis which fuses naturally to the bone. Cementless prostheses have micropores that the femur can grow into and create a strong permanent bond. The other end of the prosthesis is inserted into an artificial cup that is placed within the socket of the existing joint in the pelvis.
There are several options for the material and design of the replacement hip. One common pairing is a metal and plastic combination wherein the replacement socket is plastic and the ball joint is metal. Stainless steel is often chosen for its low reactivity, although some patients opt for titanium instead. A newer option is a ceramic prosthesis, although these have not been around long enough to prove their longevity. They have a high standard to meet, though. Traditional total hip replacement with a stainless steel and plastic prosthesis can be expected to last well over twenty years. Eighty percent of all replacements last longer than twenty years, and over half last longer than thirty. Of course, the younger a patient is, the more physically demanding they will be on it and the longer they will need it to last. This is an inherent flaw in the process of joint replacement that can only be solved through the eventual replacement of the replaced joint. A second replacement is known as a revision hip replacement. Revisions do not last as long as the initial replacement, but it is rare for a patient to need more than one revision.
This is due to the fact that a typical candidate for total hip replacement surgery is older (above the age of fifty) with oste
oarthritis of the hip. Osteoarthritis is caused by normal wear and tear on the joint as a component of the aging process, and is detailed in the image at left. In this common form of arthritis, the cartilage separating the two bones wears away and leaves the bones to rub against each other. This can be very painful and in some cases will render the joint immobile. Men around the age of forty-five begin to become candidates for osteoarthritis, and women catch up by around age fifty-five. With this in mind, it is easy to see how pretty much anyone could find themselves in need of a hip replacement at some point in their life. According to the Central Ohio Orthopedics Center, Over 166,000 hip replacements are done annually in the United States, with more than one third of those going to patients below the age of sixty-five.
Given that so many patients are elderly, it is imperative that infection and post-operative complications be kept to a minimum. This is where the mini hip replacement comes in. In the traditional surgery, a relatively large incision is made either posterior, lateral or anterior to the joint. This incision is made large enough to allow the surgeon full access to the joint and the surrounding muscle, tendons, and ligaments. With the entire area in full view, replacement and alignment is a fairly straightforward process. The mini hip replacement, on the other hand, involves two smaller incisions. One of these incisions is made posterior to the joint and the other is lateral. These smaller incisions reduce the risk of infection by limiting the amount of exposure to everything outside of the body. With the two access points it is possible for the surgeon to remove the deteriorated joint, insert the prosthesis, and cement it in place without ever actually seeing what is going on directly. Instead, x-rays and cameras help with the alignment of the prosthesis within the body.
As one can imagine, this is a difficult procedure. In spite of the fact that patients who undergo a mini hip replacement can be walking again the next day, not many surgeons are performing it because it is so much more difficult than the open procedure. Since the surgery itself is more difficult, there is a greater chance for error on behalf of the surgeon. These mistakes usually appear minor, such as a slight misalignment of the prosthesis, but they can lead to larger consequences later. Mini hip replacement recipients are at a greater risk for prosthesis dislocation than total hip replacement recipients. Dislocation of a prosthesis is a very serious problem that can only be corrected by a revision replacement.
From what I have read in the available literature, it seems to me that the mini hip replacement is not yet ready to completely replace the full hip replacement. The benefits of the mini procedure do not outweigh the possible consequences of a surgical mistake. After all, what good does it do to get out of the hospital a few days sooner if you may be setting yourself up for a revision ten years sooner? I cannot say that there is no hope for this new technique though. In the future, surgeons may very well become more proficient at the mini procedure. When they do it will be an excellent alternative for someone who needs a hip replacement but due to poor health cannot risk an open procedure.
The total hip replacement procedure is one of the oldest and most successful orthopedic operations performed today. No other joint can be replaced as easily or completely as the hip. The procedure is performed exactly the way it sounds.
The entire hip joint is removed from its socket and sawn off of the top of the femur. An artificial prosthesis (image to the right) is then inserted into the core of the femur and locked into place with methyl methacrylate, a bony cement. Younger or more physically demanding patients can chose a cementless prosthesis which fuses naturally to the bone. Cementless prostheses have micropores that the femur can grow into and create a strong permanent bond. The other end of the prosthesis is inserted into an artificial cup that is placed within the socket of the existing joint in the pelvis.There are several options for the material and design of the replacement hip. One common pairing is a metal and plastic combination wherein the replacement socket is plastic and the ball joint is metal. Stainless steel is often chosen for its low reactivity, although some patients opt for titanium instead. A newer option is a ceramic prosthesis, although these have not been around long enough to prove their longevity. They have a high standard to meet, though. Traditional total hip replacement with a stainless steel and plastic prosthesis can be expected to last well over twenty years. Eighty percent of all replacements last longer than twenty years, and over half last longer than thirty. Of course, the younger a patient is, the more physically demanding they will be on it and the longer they will need it to last. This is an inherent flaw in the process of joint replacement that can only be solved through the eventual replacement of the replaced joint. A second replacement is known as a revision hip replacement. Revisions do not last as long as the initial replacement, but it is rare for a patient to need more than one revision.
This is due to the fact that a typical candidate for total hip replacement surgery is older (above the age of fifty) with oste
oarthritis of the hip. Osteoarthritis is caused by normal wear and tear on the joint as a component of the aging process, and is detailed in the image at left. In this common form of arthritis, the cartilage separating the two bones wears away and leaves the bones to rub against each other. This can be very painful and in some cases will render the joint immobile. Men around the age of forty-five begin to become candidates for osteoarthritis, and women catch up by around age fifty-five. With this in mind, it is easy to see how pretty much anyone could find themselves in need of a hip replacement at some point in their life. According to the Central Ohio Orthopedics Center, Over 166,000 hip replacements are done annually in the United States, with more than one third of those going to patients below the age of sixty-five.Given that so many patients are elderly, it is imperative that infection and post-operative complications be kept to a minimum. This is where the mini hip replacement comes in. In the traditional surgery, a relatively large incision is made either posterior, lateral or anterior to the joint. This incision is made large enough to allow the surgeon full access to the joint and the surrounding muscle, tendons, and ligaments. With the entire area in full view, replacement and alignment is a fairly straightforward process. The mini hip replacement, on the other hand, involves two smaller incisions. One of these incisions is made posterior to the joint and the other is lateral. These smaller incisions reduce the risk of infection by limiting the amount of exposure to everything outside of the body. With the two access points it is possible for the surgeon to remove the deteriorated joint, insert the prosthesis, and cement it in place without ever actually seeing what is going on directly. Instead, x-rays and cameras help with the alignment of the prosthesis within the body.
As one can imagine, this is a difficult procedure. In spite of the fact that patients who undergo a mini hip replacement can be walking again the next day, not many surgeons are performing it because it is so much more difficult than the open procedure. Since the surgery itself is more difficult, there is a greater chance for error on behalf of the surgeon. These mistakes usually appear minor, such as a slight misalignment of the prosthesis, but they can lead to larger consequences later. Mini hip replacement recipients are at a greater risk for prosthesis dislocation than total hip replacement recipients. Dislocation of a prosthesis is a very serious problem that can only be corrected by a revision replacement.
From what I have read in the available literature, it seems to me that the mini hip replacement is not yet ready to completely replace the full hip replacement. The benefits of the mini procedure do not outweigh the possible consequences of a surgical mistake. After all, what good does it do to get out of the hospital a few days sooner if you may be setting yourself up for a revision ten years sooner? I cannot say that there is no hope for this new technique though. In the future, surgeons may very well become more proficient at the mini procedure. When they do it will be an excellent alternative for someone who needs a hip replacement but due to poor health cannot risk an open procedure.
3/3/08
Building a Better Blog: Getting My Linkroll Up To Date
This week, I again chose not to write a specific blog post, but instead opted to search around the web to find excellent sites that I could add to my linkroll (on the right). Using the Webby Awards and the IMSA criteria, I was able to find high quality personal blogs, Surgical Societies, and other useful sources of information relevant to orthopedics. Ten of these excellent sites are now imbedded in my linkroll and arranged alphabetically. I am sure you will be happy with both their ease of navigation and quality of material. These sites are not maintained by amateurs – they are of the highest caliber and I am extremely happy to link to them through my blog.
Alphabetically, the first of these sites is the Orthopedics page of About.com. It is a bit busy with advertisements, but the content is written in an easy manner and the site is very user-friendly. Next is Dr. Davis’ Back and Wrist Pain Blog, which I left a comment on last week. Dr. Davis’ blog is very informative, but he uses it to promote his own practice so sometimes readers may feel like they are being advertised to indirectly. Netsurgery.com is an excellent source of videos and articles on many aspects of surgery, although the content on their site could probably be about twice the size. The North American Spine Society is, as the name suggests, our continent’s premier society for spine care awareness. Their site is beautifully done, and I found the information on their site to be very professional. Unfortunately, the formatting does not work properly with Firefox on the Mac. The Southern California Orthopedic Institute is a group with a broader interest in Orthopedics (they do not limit themselves to the spine) located in Van Nuys, California. It is hard for me to think of anything I would criticize on this site, as they have been updating and perfecting it since 1995. Spine University is an excellent source of information specifically regarding the spine, as is Spine-Health.com. They are both easy to read since they are directed at patients, but I think Spine-Health was a little busy. As far as information is concerned, though, they are both excellent.
The American Association for the Surgery of Trauma is a group dedicated to teaching the proper treatment of traumatic injuries requiring surgery. Many such injuries require orthopedic surgery, so I deemed this site relevant to my blog. Their site is directed at surgeons more than patients, to the information can be a bit hard to read, but it is quality nonetheless. The American Medical Association is one of the foremost societies for physicians in America, and their site reflects that fact. Like the AAST though, their site is directed at doctors rather than patients, so the site can be hard to use. The Knee Foundation is dedicated to raising money for helping those with knee problems, so their site is focused more on explaining the need for aid than providing information to patients. Trauma.org is an organization very similar to the American Association for the Surgery of Trauma, and their site includes some great photos and videos of trauma surgery. Last, but not least, is Wheeless’ Textbook of Orthopedics, which is an outstanding site full of and encyclopedic amount of information on Orthopedics. The site is very intuitive, and is elegant in design. Navigation is as easy as clicking on a body part represented by the skeleton at right (note: clicking the skeleton here will merely link to the Wheeless' site, clicking on it there will direct you to the area of your interest). If anything, tere is simply too much information on this site, so getting lost or distracted is a definite possibility.
I hope you enjoy these links, as they have proved to be very helpful to me in my general search for information on Orthopedics. I will certainly be citing them in the next few weeks, and I enthusiastically look forward to doing so.
Alphabetically, the first of these sites is the Orthopedics page of About.com. It is a bit busy with advertisements, but the content is written in an easy manner and the site is very user-friendly. Next is Dr. Davis’ Back and Wrist Pain Blog, which I left a comment on last week. Dr. Davis’ blog is very informative, but he uses it to promote his own practice so sometimes readers may feel like they are being advertised to indirectly. Netsurgery.com is an excellent source of videos and articles on many aspects of surgery, although the content on their site could probably be about twice the size. The North American Spine Society is, as the name suggests, our continent’s premier society for spine care awareness. Their site is beautifully done, and I found the information on their site to be very professional. Unfortunately, the formatting does not work properly with Firefox on the Mac. The Southern California Orthopedic Institute is a group with a broader interest in Orthopedics (they do not limit themselves to the spine) located in Van Nuys, California. It is hard for me to think of anything I would criticize on this site, as they have been updating and perfecting it since 1995. Spine University is an excellent source of information specifically regarding the spine, as is Spine-Health.com. They are both easy to read since they are directed at patients, but I think Spine-Health was a little busy. As far as information is concerned, though, they are both excellent.
The American Association for the Surgery of Trauma is a group dedicated to teaching the proper treatment of traumatic injuries requiring surgery. Many such injuries require orthopedic surgery, so I deemed this site relevant to my blog. Their site is directed at surgeons more than patients, to the information can be a bit hard to read, but it is quality nonetheless. The American Medical Association is one of the foremost societies for physicians in America, and their site reflects that fact. Like the AAST though, their site is directed at doctors rather than patients, so the site can be hard to use. The Knee Foundation is dedicated to raising money for helping those with knee problems, so their site is focused more on explaining the need for aid than providing information to patients. Trauma.org is an organization very similar to the American Association for the Surgery of Trauma, and their site includes some great photos and videos of trauma surgery. Last, but not least, is Wheeless’ Textbook of Orthopedics, which is an outstanding site full of and encyclopedic amount of information on Orthopedics. The site is very intuitive, and is elegant in design. Navigation is as easy as clicking on a body part represented by the skeleton at right (note: clicking the skeleton here will merely link to the Wheeless' site, clicking on it there will direct you to the area of your interest). If anything, tere is simply too much information on this site, so getting lost or distracted is a definite possibility.I hope you enjoy these links, as they have proved to be very helpful to me in my general search for information on Orthopedics. I will certainly be citing them in the next few weeks, and I enthusiastically look forward to doing so.
2/18/08
Learning More: Cutting-Edge Treatment For Back Pain
This week I decided to check out other blogs to see what more I could learn about treatment of lower back pain. I was pleased to find that there are many blogs dedicated to this very subject. One such blog described a new spinal decompression machine that looks to be a good step forward in limiting the role of surgery in back pain treatment. I read the post concerning this machine and found that I had a few questions to ask the author, 
Dr. Eben Davis. Dr. Davis is a chiropractor in San Francisco who specializes in non-surgical methods of back and wrist pain treatment. I left a comment on his blog asking for help understanding the benefits of the new decompression machine, and I hope to hear back from him soon. For your convenience, I am also including the full text of my comment below. As I continued searching through the blogosphere, I came upon another excellent blog dealing with orthopedics, aptly titled "Orthopedic." One post on this blog was dedicated to the discussion of spinal surgical techniques. As I had a few questions about these procedures, I also left a comment there. As with my first post, it is also available in full text below.
"What is Degenerative Disc Disease? Can the DRX9000 Help?"
Comment:
"Hi Dr. Davis, I’m a student at the University of Southern California and I have a great interest in spinal therapy for a couple of reasons. First of all, I suffer from sciatica due to a herniated disc. Secondly, I plan to go to med school after graduation and I’m currently looking at orthopedics as a specialty.
I think that this new machine looks like a great treatment method for people with back pain. Surgery should be kept as a last resort, and innovative ideas like this will surely help reinforce that. How long does one session on the DRX machine provide relief for a patient? I saw on the DRX website that the treatment effectively relieves pressure on lumbar discs that are bulging or even ruptured. What I don’t understand is how the disc returns to normal after the pressure is relieved. If a disc has ruptured, how does it pull itself back together all of a sudden during this treatment? I can imagine that a herniated disc might be able to reassume a normal shape, but is there really any way that a patient with a ruptured disc can get an effective resolution of pain non-surgically?
Additionally, how do you feel about this new article published in the British Medical Journal last week (http://www.sciencedaily.com/releases/2008/01/080131214541.htm) saying that stretching does not effectively decrease back pain? I personally disagree with these results, as I have achieved almost complete success through stretching and exercising my back over the last 18 months since my injury. Basic yoga has done worlds of good for me. When my back tightens up, whether as a result of stress or bad posture, I always find the most relief from stretching on the floor in the Cobra Pose. I also have worked to strengthen my lower back with the Full Locust Pose. Of course, my personal success with this kind of treatment does not necessarily prove its validity in general.
I am looking forward to learning more about this field, so any insights you could offer would be greatly appreciated."
"What are the Spinal Orthopedic Procedures?"
Comment:
"Great post – it’s hard to find good information on these techniques online. I hadn’t realized that some surgeons operate from the front of the patient when operating on the spine. What is the benefit of this approach? I had thought that herniations occurred on the posterior side of lumbar and/or cervical discs.
What are your thoughts on non-surgical treatments for disc herniations? I have been researching this for a while, and it seems like many people have personal success stories with alternative treatments like yoga and spinal decompression with a chiropractor, but the medical community at large seems to disagree. What, in your opinion, is the best treatment plan from injury to full resolution of pain? I suffered a herniated lumbar disc about 18 months ago, and I have always kept surgery as a last resort. I have instead taken the non-invasive route and tried my best at yoga, with some dramatic success. As of now, I am almost 100% pain free.
I think that the idea of minimally invasive spinal surgery is a great one. It’s amazing that the same goal can be met either with a hazardous open procedure or a relatively benign laparoscopic one. How long have minimally invasive surgeries been around for the spine? I have read on numerous sites that they are new, but I haven’t seen any actual dates.
Once again, thank you for posting this here – a good resource is invaluable for someone looking for information on back pain treatments. Surgery, especially, is never really discussed in any sense other than outcomes. Plenty of people write about their own experiences with surgery, but you are the first I have seen to write in detail about each of the different options."
Dr. Eben Davis. Dr. Davis is a chiropractor in San Francisco who specializes in non-surgical methods of back and wrist pain treatment. I left a comment on his blog asking for help understanding the benefits of the new decompression machine, and I hope to hear back from him soon. For your convenience, I am also including the full text of my comment below. As I continued searching through the blogosphere, I came upon another excellent blog dealing with orthopedics, aptly titled "Orthopedic." One post on this blog was dedicated to the discussion of spinal surgical techniques. As I had a few questions about these procedures, I also left a comment there. As with my first post, it is also available in full text below."What is Degenerative Disc Disease? Can the DRX9000 Help?"
Comment:
"Hi Dr. Davis, I’m a student at the University of Southern California and I have a great interest in spinal therapy for a couple of reasons. First of all, I suffer from sciatica due to a herniated disc. Secondly, I plan to go to med school after graduation and I’m currently looking at orthopedics as a specialty.
I think that this new machine looks like a great treatment method for people with back pain. Surgery should be kept as a last resort, and innovative ideas like this will surely help reinforce that. How long does one session on the DRX machine provide relief for a patient? I saw on the DRX website that the treatment effectively relieves pressure on lumbar discs that are bulging or even ruptured. What I don’t understand is how the disc returns to normal after the pressure is relieved. If a disc has ruptured, how does it pull itself back together all of a sudden during this treatment? I can imagine that a herniated disc might be able to reassume a normal shape, but is there really any way that a patient with a ruptured disc can get an effective resolution of pain non-surgically?
Additionally, how do you feel about this new article published in the British Medical Journal last week (http://www.sciencedaily.com/releases/2008/01/080131214541.htm) saying that stretching does not effectively decrease back pain? I personally disagree with these results, as I have achieved almost complete success through stretching and exercising my back over the last 18 months since my injury. Basic yoga has done worlds of good for me. When my back tightens up, whether as a result of stress or bad posture, I always find the most relief from stretching on the floor in the Cobra Pose. I also have worked to strengthen my lower back with the Full Locust Pose. Of course, my personal success with this kind of treatment does not necessarily prove its validity in general.
I am looking forward to learning more about this field, so any insights you could offer would be greatly appreciated."
"What are the Spinal Orthopedic Procedures?"
Comment:
"Great post – it’s hard to find good information on these techniques online. I hadn’t realized that some surgeons operate from the front of the patient when operating on the spine. What is the benefit of this approach? I had thought that herniations occurred on the posterior side of lumbar and/or cervical discs.
What are your thoughts on non-surgical treatments for disc herniations? I have been researching this for a while, and it seems like many people have personal success stories with alternative treatments like yoga and spinal decompression with a chiropractor, but the medical community at large seems to disagree. What, in your opinion, is the best treatment plan from injury to full resolution of pain? I suffered a herniated lumbar disc about 18 months ago, and I have always kept surgery as a last resort. I have instead taken the non-invasive route and tried my best at yoga, with some dramatic success. As of now, I am almost 100% pain free.
I think that the idea of minimally invasive spinal surgery is a great one. It’s amazing that the same goal can be met either with a hazardous open procedure or a relatively benign laparoscopic one. How long have minimally invasive surgeries been around for the spine? I have read on numerous sites that they are new, but I haven’t seen any actual dates.
Once again, thank you for posting this here – a good resource is invaluable for someone looking for information on back pain treatments. Surgery, especially, is never really discussed in any sense other than outcomes. Plenty of people write about their own experiences with surgery, but you are the first I have seen to write in detail about each of the different options."
2/11/08
Lower Back Pain Treatment: Are Orthopedic Surgeons Hiding Something From Their Patients?
There are several key areas of orthopedic surgery that are current and developing enough to warrant timely blog posts. One of these is the treatment of lower back pain. This is of particular interest to me, as I have herniated a lumbar disc myself. 
I am not in a rare situation though. Lower back pain is a major financial burden for Americans, as a Duke University study found that the annual cost of lower back pain treatment in America exceeded $25 billion, or 2.5% of all national healthcare expenses.
Lower back pain manifests itself in two forms: axial and radicular. Axial pain is concentrated in the lower back and can be caused by aggravation of the soft tissue surrounding the spine. Improper lifting technique, for example, can put strain on the tendons and ligaments that support the spine, and thus allow more severe damages to take place. These can lead to radicular pain, or pain that is no longer confined to the lower back. Radicular pain is often referred to as sciatica. A patient typically suffers from pain that shoots down one or both legs, either intermittently or chronically. At its worst, this pain can be accompanied by numbness or loss of strength in the affected limb or limbs.
The anatomy of a sciatica-stricken lower back is fairly simple. Each vertebra in the spine is separated from its neighbor by a lumbar disc. The primary function of this disc is shock absorption. Lumbar discs are shaped like a jelly doughnut. They have a tough outer layer, known as the annulus fibrosus, and a softer inner layer, called the nucleus pulposus. See diagram below for clarification. When a disc ruptures or becomes herniated, the nucleus pulposus pushes out into the space normally contained by the annulus fibrosus. This makes the disc as a whole bulge out into the surrounding space. A bulging disc can impinge on nerve roots that exit the spine next to the discs, and in doing so cause pain to be experienced all along the path of that nerve. When the bulging disc is in the lower back, the impinged nerve tends to run to one of the legs.
For many years, the gold standard treatment for radial lower back pain was surgery. There are several different procedures that are in common practice today, and each one has pros and cons for a given patient’s situation. In each procedure, the basic goal is the same: to relieve pain caused by nerve root impingement. One method involves shaving down the herniated portion of the disc, thus returning the outer shape of the disc to its natural curve. This releases pressure on the nerve, but permanently weakens the annulus fibrosus. Another method, known as a discectomy, involves either the removal or dissolution of the herniated disc.
The two vertebrae are then fused together to prevent any motion between them. This method can be a great relief for some patients, but it decreases flexibility in and permanently weakens the lower back. One of the more recent developments is called a total disc replacement. An interactive video detailing this procedure can be seen here.
In contrast to this newest procedure, over the past few years surgical techniques have generally become less and less invasive. Orthopedic surgeons are now commonly performing laparoscopic microdiscectomies rather than open surgeries to speed up recovery time and lessen any chance of infection. Treatment plans have similarly taken a step away from the traditional surgery route. Many surgeons now advise that surgery is not necessary for any patients but those with the most serious disc herniations. Each of the twenty-four orthopedic surgeons who gave their opinions on back.com felt that the best course of action is to start with rest and non-steriodal anti-inflammatory drugs (NSAIDs), then advance to exercise and stretching, then try cortisone injections around the affected area, and finally to proceed to surgery if nothing else has given the patient relief. It is amazing how uniform this treatment plan is from doctor to doctor. It is not by any means the only method prescribed by doctors around the country, but it evidently has a pretty strong following.
There are a few issues with this treatment plan. Several recently published studies contradict the idea that following this protocol will lead to resolution of lower back pain. The first, a recent review of 65 studies comprising over 11,000 subjects with lower back pain, has concluded that NSAIDs like ibuprofen are no more effective at treating symptoms from radial pain than simple painkillers such as Tylenol. It also concluded that NSAIDs were only slightly effective at relieving pain for these subjects. Another study published by the British Medical Journal has shown that exercises and lifting technique education are not effective at relieving back pain. As written in Science Daily, “a group receiving both training and an assistive device was compared to a group receiving training only and another control group which received nothing -- there was no difference in back pain [after one year].”
I find it very odd that orthopedic surgeons would be advocating a treatment plan that calls for NSAIDs, education on posture and lifting, and stretching and exercises for the back considering that these elements of the treatment have been shown to be ineffective. Is it possible that these surgeons know that eventually their patients will come crawling back for surgery after months of ineffective exercise and stretching? Many people are averse to the idea of having surgery on their back and will only consent when they feel it is their only option for relief. If surgeons were only promoting alternative therapies to add credence to their own surgical specialty, then what a wicked game that would be.
I cannot believe that any medical professional would knowingly give out bad information to a patient simply to make surgery seem like a better option. Instead, I think that these surgeons believe that many back pain sufferers can simply get better on their own. Given time, many (some estimate up to 80%) patients will regain most of their strength and learn to live with whatever pain lingers. I believe that what the common treatment plan does is give the majority of patients the time that is necessary to begin to heal themselves without surgery. After all, this has been my own personal experience with back pain. I herniated a disc in my lower back almost 18 months ago, and I am finally to the point where I could declare myself as being 90% better. I was given the standard treatment plan – first rest and painkillers, then stretching and exercise, and I was told that surgery would be held as a last resort. I ended up not taking that last resort because my pain went away quickly enough. The stretching and exercise involved with this treatment plan worked well for me because it gave me something to do while I waited for my pain to go away. Whether it went away because of what I was doing or simply on its own does not matter because in either case, I recovered. And when it comes to lower back pain, that’s really what counts.
I am not in a rare situation though. Lower back pain is a major financial burden for Americans, as a Duke University study found that the annual cost of lower back pain treatment in America exceeded $25 billion, or 2.5% of all national healthcare expenses.Lower back pain manifests itself in two forms: axial and radicular. Axial pain is concentrated in the lower back and can be caused by aggravation of the soft tissue surrounding the spine. Improper lifting technique, for example, can put strain on the tendons and ligaments that support the spine, and thus allow more severe damages to take place. These can lead to radicular pain, or pain that is no longer confined to the lower back. Radicular pain is often referred to as sciatica. A patient typically suffers from pain that shoots down one or both legs, either intermittently or chronically. At its worst, this pain can be accompanied by numbness or loss of strength in the affected limb or limbs.
The anatomy of a sciatica-stricken lower back is fairly simple. Each vertebra in the spine is separated from its neighbor by a lumbar disc. The primary function of this disc is shock absorption. Lumbar discs are shaped like a jelly doughnut. They have a tough outer layer, known as the annulus fibrosus, and a softer inner layer, called the nucleus pulposus. See diagram below for clarification. When a disc ruptures or becomes herniated, the nucleus pulposus pushes out into the space normally contained by the annulus fibrosus. This makes the disc as a whole bulge out into the surrounding space. A bulging disc can impinge on nerve roots that exit the spine next to the discs, and in doing so cause pain to be experienced all along the path of that nerve. When the bulging disc is in the lower back, the impinged nerve tends to run to one of the legs.
For many years, the gold standard treatment for radial lower back pain was surgery. There are several different procedures that are in common practice today, and each one has pros and cons for a given patient’s situation. In each procedure, the basic goal is the same: to relieve pain caused by nerve root impingement. One method involves shaving down the herniated portion of the disc, thus returning the outer shape of the disc to its natural curve. This releases pressure on the nerve, but permanently weakens the annulus fibrosus. Another method, known as a discectomy, involves either the removal or dissolution of the herniated disc.
The two vertebrae are then fused together to prevent any motion between them. This method can be a great relief for some patients, but it decreases flexibility in and permanently weakens the lower back. One of the more recent developments is called a total disc replacement. An interactive video detailing this procedure can be seen here.In contrast to this newest procedure, over the past few years surgical techniques have generally become less and less invasive. Orthopedic surgeons are now commonly performing laparoscopic microdiscectomies rather than open surgeries to speed up recovery time and lessen any chance of infection. Treatment plans have similarly taken a step away from the traditional surgery route. Many surgeons now advise that surgery is not necessary for any patients but those with the most serious disc herniations. Each of the twenty-four orthopedic surgeons who gave their opinions on back.com felt that the best course of action is to start with rest and non-steriodal anti-inflammatory drugs (NSAIDs), then advance to exercise and stretching, then try cortisone injections around the affected area, and finally to proceed to surgery if nothing else has given the patient relief. It is amazing how uniform this treatment plan is from doctor to doctor. It is not by any means the only method prescribed by doctors around the country, but it evidently has a pretty strong following.
There are a few issues with this treatment plan. Several recently published studies contradict the idea that following this protocol will lead to resolution of lower back pain. The first, a recent review of 65 studies comprising over 11,000 subjects with lower back pain, has concluded that NSAIDs like ibuprofen are no more effective at treating symptoms from radial pain than simple painkillers such as Tylenol. It also concluded that NSAIDs were only slightly effective at relieving pain for these subjects. Another study published by the British Medical Journal has shown that exercises and lifting technique education are not effective at relieving back pain. As written in Science Daily, “a group receiving both training and an assistive device was compared to a group receiving training only and another control group which received nothing -- there was no difference in back pain [after one year].”
I find it very odd that orthopedic surgeons would be advocating a treatment plan that calls for NSAIDs, education on posture and lifting, and stretching and exercises for the back considering that these elements of the treatment have been shown to be ineffective. Is it possible that these surgeons know that eventually their patients will come crawling back for surgery after months of ineffective exercise and stretching? Many people are averse to the idea of having surgery on their back and will only consent when they feel it is their only option for relief. If surgeons were only promoting alternative therapies to add credence to their own surgical specialty, then what a wicked game that would be.
I cannot believe that any medical professional would knowingly give out bad information to a patient simply to make surgery seem like a better option. Instead, I think that these surgeons believe that many back pain sufferers can simply get better on their own. Given time, many (some estimate up to 80%) patients will regain most of their strength and learn to live with whatever pain lingers. I believe that what the common treatment plan does is give the majority of patients the time that is necessary to begin to heal themselves without surgery. After all, this has been my own personal experience with back pain. I herniated a disc in my lower back almost 18 months ago, and I am finally to the point where I could declare myself as being 90% better. I was given the standard treatment plan – first rest and painkillers, then stretching and exercise, and I was told that surgery would be held as a last resort. I ended up not taking that last resort because my pain went away quickly enough. The stretching and exercise involved with this treatment plan worked well for me because it gave me something to do while I waited for my pain to go away. Whether it went away because of what I was doing or simply on its own does not matter because in either case, I recovered. And when it comes to lower back pain, that’s really what counts.
Subscribe to:
Posts (Atom)
