Most patients referred to a spine surgeon do not require surgery, but are simply being referred because their case is beyond the expertise of their primary care provider. At the initial evaluation, there will be a complete history and physical, and review of any testing already performed. X-rays may be taken during the visit, and then either a treatment plan or additional testing will be recommended. If surgery is recommended, the details will be fully reviewed and all questions will be answered. No decision regarding surgery is expected from the patient during the visit, except in instances where a true neurological emergency exists. In such cases, immediate admission to the hospital would typically be advised.
Rarely, extremely complicated cases, particulary if multiple areas in the spine have disease, may require scheduling a second visit for further consultation if time does not allow all aspects of the case to be fully discussed.
If your X-rays, MRI, CT scan, or bone scan has been performed on a Mountain States Health Alliance or Wellmont facility, the study can typically be reviewed online, unless those systems are having severe technical issues—and that does happen occasionally. An important exception to this is Unicoi County Memorial Hospital—even though this is a Mountain States facility, its images are not available to medical staff online. So if you have a study from Unicoi County, or any other facility outside of Wellmont or Mountain States, you must bring the images on a CD at the time of your appointment. The facility cannot send the images to Appalachian Orthopaedics, even if you think they said they could. They only have the ability to send the report, which is not sufficient for an evaluation with the surgeon. This misunderstanding can cause a wasted appointment, so please make sure to bring your images if this applies to you.
This is an excellent question, and answering it correctly takes time. The science of spine surgery has come a long way in the past 20 years. In order to be a good candidate for spine surgery, a patient must have a clearly defined problem that surgery can help. This sounds simple, but the reality gets more complicated. There are three common conditions that have been scientifically shown to respond well to surgery: a) herniated disc, a pinched nerve from disc material, b) spinal stenosis, a pinched nerve from bone spurs/narrowed spinal canal, and c) spinal instability, a slippage or alignment problem of one or more vertebrae (spine bones), usually either a condition called spondylolisthesis or scoliosis.
On the other hand, there is another extremely common condition of the spine that does not respond reliably to surgery, and it is referred to as disc degeneration, or degenerative disc disease. This is essentially an age or wear-and-tear related loss of cushioning between the vertebrae, and can cause pain and stiffness. Sometimes this occurs in an every-day, achy way, and sometimes there are acute episodes where people experience their neck or back “going out” with severe pain, inability to move, and a feeling that something is seriously wrong. The vast majority of these severe episodes, even though quite frightening, get better on their own and the patient typically returns to their usual state of health in a few days or weeks. The long term results of surgery for disc degeneration, whether it be fusion or disc replacement, leave a lot to be desired. It is often very difficult to determine which degenerative disc is causing a problem, and in many instances, there is more than one painful disc. Even if the bad disc is identified, other discs can either continue to cause problems or get worse in the future. Unfortunately, many patients in America come to the conclusion that their degenerative disc problem is so bad that something must be done, and they submit to surgery. There is no shortage of spine surgeons willing to perform these operations. A lot of these patients would have been better off getting their spines more healthy with weight loss, smoking cessation, and a good spinal rehabilitation exercise program. Instead, they have surgery, end up with a poor result, and give spine surgery a bad name.
Another point: Most patients with surgically treatable spine conditions already have a degree of disc degeneration in one stage or another. It is important that these patients understand which symptoms the surgery will help. If a patient has a discectomy for leg pain, they can continue to have backache from the disc degeneration, and this is not necessarily considered to be a true failure or complication of the surgery.
The other common reasons for poor results from spine surgery are irreversible nerve damage that has taken hold before surgery, and poor overall health. The old thinking about a pinched nerve from a spine problem was to wait until you couldn’t stand it any more, and only then have surgery. We now know that this is not true: it turns out that, at least in general, the sooner a nerve is unpinched, the more likely it is to make a full recovery. This is actually common sense: if something is causing damage, get rid of the cause as soon as possible. An analogy would be this: if you had a tumor in your brain that was pushing on it, would you wait until you couldn’t stand it any more? Now, this principle doesn’t necessarily apply in cases of mild or temporary problems. The most important example would be a herniated disc, which can cause severe pain and weakness temporarily, but the herniation will dry out and shrink over time, so urgent surgery isn’t always necessary.
Patients in poor overall health have difficulty healing any kind of surgery, including those on the spine, and any nerve injury that has occurred is less likely to recover. An ethical, experienced spine surgeon will tell certain patients that they are too old, or too sick for surgery.
This question comes up frequently and there are several misconceptions about differences between these types of spine surgeons. Orthopedic spine surgeons complete an orthopedic residency followed by a spine fellowship and receive training in orthopedics (which includes the arms, legs, and spine). Neurosurgeons complete a neurosurgical residency and also receive training in brain surgery. The most important thing to remember is that the vast majority of spine conditions are treated by both types of surgeons, and that differences between individual surgeons are much greater than differences between the specialties. In fact, if you looked at the O.R. schedule of a large nonacademic hospital, you would not notice much, if any difference between the schedule of the neurosurgeon and the orthopedic spine surgeon; most of the surgeries would be on patients who have degenerative conditions of the neck and lower back, with an occasional fracture case. You should select a surgeon who is well trained, and has a reputation in his community for being skilled in his profession and for being honest in advising patients about whether surgery is right for them.
Some patients wonder whether a “neuro”surgeon will be handle their nerve tissue any differently during surgery. Since patients are naturally fearful of the possibility of nerve injury from a spine operation, this is an understandable concern. However, the answer is really quite simple: the basic principles and techniques that are used to decompress (“unpinch”) nerves during spine surgery are the same regardless of the surgeon’s specialty. The minor differences in technique that exist are greater between individual surgeons than they are between specialties, and vary primarily due to who the surgeon trained under, and subsequent experience with the development of personal preferences. It is better to see a good orthopedic spine surgeon than a mediocre neurosurgeon, and it is better to see a good neurosurgeon than a mediocre orthopedic spine surgeon.
With that said, there are some differences between the specialties. Orthopedic spine surgeons are also trained in the management of spinal deformities, including scoliosis and kyphosis. Some orthopedic spine surgeons develop a special interest in these relatively long and difficult surgeries, and are known as deformity spine surgeons. While most orthopedic spine surgeons receive training in deformity surgery during their spine fellowships, it is a common practice to give up performing these more complex surgeries and refer those cases out. This could be to a deformity spine surgeon, or in some instances with childhood scoliosis, a pediatric orthopedist. Still, this extra training experience in deformity gives the orthopedic spine surgeon a good background in helping him decide when a case is too complicated for him to tackle. Many orthopedic spine surgeons, even if they have given up performing scoliosis surgery on children, are still happy to see scoliosis patients in the office, evaluate their curvatures, prescribe bracing when appropriate, and refer out for surgery when necessary.
Neurosurgeons are also trained in operations on conditions affecting the nerve tissue itself. The most important examples of this include the relatively uncommon conditions of spinal cord tumors, and syringomyelia, which is an expanding cavity of spinal fluid that forms in the center of the spinal cord and sometimes can benefit from the implantation of a small drainage tube. These differences between the specialties only affect a small percentage of the overall number of spine surgeries performed.
Because the orthopedic spine surgeon has completed an orthopedic residency, he is well versed in the physical examination and diagnosis of other conditions that are frequently confused with spine disease, particularly diseases of the shoulder, elbow, hip and knee. This confusion occurs for the simple reason that these joints are in the same areas where nerve pain from the spine often radiates. It is not too unusual to recover from a spine operation and discover that unfortunately there is still pain coming from one of these joints, or vise versa. A thorough physical examination in the areas where pain is radiating to is an important part of evaluating a spine condition, and the orthopedic spine surgeon has expertise in this area based on his training. If you do have another orthopedic problem, he will probably have a partner in his office who is an expert on it, and with whom he can coordinate care. If you just need a steroid injection for a non-spine problem, the orthopedic spine surgeon is often himself willing to perform that for you and save you an extra visit.
Occasionally a spine condition deteriorates to the point where emergency hospital admission is required, either for pain control or surgery. If you have any of the following: a) pain so severe that medication does not control it and you cannot sleep or function, b) severe weakness in an arm or leg, or c) numbness in the genital area or loss of control of bowel or bladder, then you may need a hospital admission. You should contact the office or answering service and explain your situation. You may be directed either to the office or the Emergency Room. If you do go to the Emergency Room, it is important that you identify yourself as an Appalachian Orthopaedic patient. Normally the office or on-call physician will notify the Emergency Room to expect you, but on occasion this information can fail to reach the right person, so it is a good idea to clarify that when you arrive.
Heavy national advertising by some spine surgery
organizations has led to the public perception that “laser spine surgery” is a
truly innovative and superior product.
What some organizations promote as a “band aid operation” with a less
than one inch incision, is actually a common spine operation known as a tubular
access, or minimally invasive, microdiscectomy, for a diagnosis of herniated
disc. Or, if the diagnosis is spinal
stenosis (bone spurs), the procedure will be referred to slightly differently,
as a minimally invasive laminotomy, or possibly laminoforaminotomy.
In these operations, a roughly ¾” diameter tube is pushed
through the back muscles down to the spine, and under an operating microscope,
the spinal canal is entered and the pinched nerves are unpinched, or
decompressed, by conventional spine surgery techniques. Either herniated disc material is separated
off of spinal nerves and removed, or bone spurs that are compressing spinal
nerves are shaved away. Any spine
surgeon who has kept up with minimally invasive techniques performs these
However, at some spine surgery providers, the procedure is
supplemented by deadening the small sensory nerve fibers on the outside of the
spine bones with a laser, a technique formally known as a medial branch
ablation, or facet neurotomy. This is
claimed by its proponents to reduce postoperative pain in the spine itself.
This claim, to the best of the knowledge of Appalachian
Orthopaedics, upon review of the available medical literature, has not been
scientifically proven by any randomized controlled trials to be true at long
term follow-up, nor is there any evidence that by combining these two
procedures, there are better long term outcomes. Furthermore, it is widely recognized in the
medical literature that the pain relief that does come from medial branch
ablations is usually neither complete nor permanent, as the deadened nerves
tend to grow back. In fact, patients who
have medial branch ablations for other legitimate reasons very often have the
procedure repeated several times because of this tendency.
Hence, the most important part of the operation, unpinching
the nerves within the spinal canal to relieve leg pain, is NOT even performed
with the laser, but by conventional, widely performed techniques. In the opinion of Appalachian Orthopaedics,
the “band aid operation” combined with the laser, offered by some spine surgery
providers, offers no scientifically proven advantage to a conventional
minimally invasive decompression, and the notion that this is a substantially
superior, “cutting edge” procedure is untrue.