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Physiatrists Surgeons |
CINN has specialists available to evaluate job requirements and susceptibility to back injuries. If you are interested in this service, please contact Lisa Dombro at ldombro@cinn.org
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Editor’s MessageThis issue of the Discussant, CINN’s electronic newsletter focusing on issues important to the work injury community, gives testament to our interest in providing you with complete and up-to-date information on non-invasive and minimally invasive treatments of back pain. Committed to employing the least invasive treatment possible in returning people to function, this issue includes a description of the effectiveness of physical therapy and home exercise in the treatment of back pain and illustrates the importance of an accurate diagnosis before pursuing a treatment strategy. CINN’s team of physiatrists specializes in making these sometimes-difficult diagnoses and offering non-surgical means of relieving associated symptoms. While the vast majority of the back pain patients treated by CINN improve without surgery, surgical intervention does provide a viable alternative for many. To this end, CINN is consistently investigating approaches that decrease the morbidity associated with traditional spine surgery. This issue of the Discussant reviews a commonly performed minimally invasive surgery, microendoscopic lumbar fusion, which reduces the blood loss, pain, hospitalization and recovery time typically associated with such procedures. Our commitment to employing the least invasive, effective, approach in treating patients is just one of the ways CINN has distinguished itself over the past 16 years. We welcome the opportunity to further collaborate with you in caring for your employees, clients and patients and expediting their return to work. Noam
Y. Stadlan, M.D. |
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Lower Back Pain: An Active Approach to Diagnosis and Treatment
Ninety percent of lower back pain (LBP) cases are benign and typically subside within six weeks regardless of treatment method. The diagnosis and treatment of the remaining 10 percent are more challenging, however, and demand strict adherence—both from the physician and the patient—to the latest clinical guidelines and recommendations. Based on current literature, a multidisciplinary approach combining drug treatment with physical and patient education has proven to be the most successful treatment of back pain.
Diagnosis
Specific treatment plans can differ significantly depending on whether the back pain is acute or chronic, radiating or non-radiating. It is therefore important to make an early and accurate diagnosis. The initial visit of an LBP patient to a general practitioner should include a thorough history and assessment of “red flags” for serious disease, as well as psychological and social risks for chronic disability. Following the initial examination, acceptable treatment options at this early stage include ice, NSAIDs, muscle relaxants and return to usual activities. Strict bed rest is not recommended. Close clinical follow up should be maintained until the patient is able to return to work and/or key life activities.
If the patient’s pain and disability do not improve or in fact worsen after a period of four weeks, consultation with a spine specialist should be considered. As most acute LBP is amenable to non-operative treatment, consultation with a physiatrist, a specialist in physical medicine and rehabilitation, is the best first step for most patients. Such consultation will help clarify the often-complex differential diagnosis of LBP and allow the institution of early aggressive conservative care.
Prior to the six-week mark, the patient’s LBP is still acute. If symptoms persist at six weeks, the LBP should be regarded as subacute. By 12 weeks the condition is chronic.
Treatment and Recovery
Oral or injectable medication may be used to manage back pain. In cases of chronic pain in compliant patients, practitioners should not be afraid to prescribe pain medication, even opioids. Adequate medication for pain allows chronic back pain patients to properly execute their home exercises, leading to a sense of control over their condition and possibly leading to lower doses of medication at a later time. In cases of acute pain, aggressive pain medication regimens are followed by rapid tapering to avoid dependence. In all cases, adequate medication is used to facilitate the exercise program.
Under the direction of a physician, physical therapists educate the patient regarding proper body mechanics and establish an individualized exercise program that enables self-management of the condition at home. Compliance with home exercise programs can be encouraged by therapists and physicians by educating patients that home exercises are the most effective “medication” for their back pain, and, just like other medications, need to be administered regularly to be beneficial.
Consistent exercise is really key for patients who suffer from back pain. Patients maintaining a home exercise program strengthen core muscles, which in turn keep pressure off of the spine. By stretching tight muscles affecting the injured area and strengthening weak muscles supporting the injured area, the patient is allowed to heal naturally.
The progression of an exercise program can be supported through treatments such as heat, ice, electrical stimulation, massage, medications, injections and manipulations. Throughout these treatments, it is recommended that the lines of communication between specialists and the patient’s general practitioner be kept open. A good PT will provide progress notes and keep the referring physician informed about potential problems or plateaus in treatment.
Lower back pain can be challenging to diagnose and treat effectively, but the continually emerging evidence in support of exercise and physical therapy treatments bodes well for present and future LBP sufferers. Exercise empowers patients to take an active role in their treatment. It also encourages the long-term prevention of repeat injury.
Minimally Invasive Spine Surgery
The first line of treatment for back pain remains conservative therapy. Depending upon the specific type of back pain, a combination of exercise, physical therapy, weight loss or selective injections may be effective. Not all patients with back pain who have failed conservative therapy are candidates for surgery. Imaging studies, especially MRI scans, need to corroborate a specific degenerative segment(s).
In some patients, back pain is caused by instability of specific vertebral bodies. Stabilizing the vertebrae can reduce or eliminate back pain. Traditional spinal fusion surgeries are fairly large surgeries and involve long recovery times and surgical injury to the muscles near the spine. A typical open procedure may involve an incision up to 6 inches long in the middle of the low back. New technologies now allow surgeons to perform the same surgeries with smaller incisions and less muscle damage.
Following is a description of a common minimally invasive procedure performed by CINN spine surgeons.
Microendoscopic lumbar fusion
Intraoperative imaging technology called fluoroscopy is used to visualize the disc space(s). A 3 cm incision is made. Tubes, called dialators are used to carefully separate the muscles to provide access to the spine, rather than stripping or cutting them as done in the traditional procedure. These sequential dialators are used to allow for the placement of a working tube (access port) approximately 26 mm in diameter by 6 cm in length. Surgery is performed through this limited access port, which involves the removal of bone and herniated disc fragments, the placement of bone graft and the positioning of an implant device (interbody device) between the vertebrae. The entire degenerated disk is removed. The normal disk space height is restored. A plastic device is inserted to maintain the disk height. A new bioengineered substance, Infuse (bone morphogenic protein) is placed to promote new healthy bone growth. Screws are placed to hold the bones in place and prevent the abnormal motion that is often responsible for lower back pain. Once the dialators are removed, the muscle returns to its pre-operative position. Because minimally invasive procedures separate muscles instead of cutting or splitting them, as done in a traditional procedure, less muscle damage is incurred by the patient and therefore less postoperative swelling and pain results. The muscles are also left intact to provide essential stability.
The procedure usually takes 3-4 hours and the patient typically remains in the hospital for approximately 2 days. It is normal for a patient to experience some postoperative pain, which will usually improve over the course of the first few days. The overall results with minimally invasive lumbar fusion surgery are similar to open surgery, with about 80-90% of patients realizing substantial improvement. After surgery, patients can return to a full lifestyle within a few weeks of surgery.
Dean Karahalios, M.D. now seeing patients at CINN offices at Highland Park Hospital
Dean
Karahalios, M.D. is seeing patients at CINN’s
Highland Park Hospital offices at 767 Park Avenue West, Suite 330.
Dean G. Karahalios, M.D., a board-certified neurosurgeon, is well versed in treating the full spectrum of neurological disorders. He is fellowship-trained in spine and a leading authority on the treatment of patients with complex spinal disorders. Dr. Karahalios is particularly well known for his use of implants, fusion systems, instrumentation, and innovative complex spine techniques to treat patients with degenerative problems, and traumatic injuries to the spine. He also has a keen interest and extensive experience in a unique and aggressive multi-modality approach to primary and metastatic tumors of the spine, which includes cutting-edge surgical approaches and spinal radiosurgery. He is highly skilled in the use of image-guided and minimally invasive surgical techniques, which reduce the risks and speed the recovery time of spine surgery.
In addition to his practice at The Neurologic & Orthopedic Hospital of Chicago, Dr. Karahalios will be performing surgeries at Evanston Hospital, Highland Park Hospital and Lake Forest Hospital. If you would like to refer a patient to Dr Karahalios, please call 847 926-5005 or 1-800-446-1234.