Sylvia, a woman well into her 70s, had played an active role in her community for years (some details changed to protect patient confidentiality). Known as a baker nonpareil, she could be relied on to whip up platefuls of cannolis, sfogliatellas, cassatas and other Italian goodies for community events. She was always on the go with friends, the type of woman, you might say, who let little grass grow under her feet.
Only, in recent years, that had changed. She was finding it more and more difficult to get around – and baking became out of the question. The burning pain and weakness traveling down her legs made standing for more than a few minutes difficult, and walking any distance near impossible. After suffering silently, taking overthe- counter pain medication and then opioids for nearly two years, she finally realized she couldn’t live like this any longer.
“Her MRI showed she had neurogenic claudication, a condition that occurs due to a compression of the spinal nerves in the lower spine that is caused by spinal stenosis,” says Dr. David Phillips, a neurosurgeon at SBH who specializes in minimally invasive spine surgery. “We’ve had very good success with minimally invasive procedures for conditions like this. Putting someone on long-term opiates is not the answer. If degenerative changes are pushing on a nerve and causing pain, surgery can alleviate that pressure and return the patient to their previous life.” In minimally invasive spine surgery, the surgeon makes one or more small incisions (about two centimeters each) through the skin. A small metal tube is placed through the incision to allow the surgeon, using a microscope, to work through a smaller operative field. By using smaller incisions, there is much less damage to surrounding muscles and soft tissues than with a single long incision. Additionally, there is reduced risk of instability and postoperative pain, faster recovery, and shorter times to return to normal activities after surgery.
“This is day surgery and we have patients walking the same day. They’re sore for a few days, take Tylenol #3 or a low dose of pain medication for one to three days after the surgery, and pretty quickly, depending on their job, are back at work without having to suffer years of pain or the serious consequences of using opioids for the long-term,” says Dr. Phillips. “Usually within a month they start to forget they had the surgery and most say they wish they had done this sooner.”
Dr. Phillips stresses that treatment decisions are made on a patient-by-patient basis – and that minimally invasive spine surgery is only one treatment option. “I don’t push this surgery on anyone, but if they could benefit from it, it’s such a really good alternative that lets people get back to their lives.”
For most people with back pain, he says, conservative modalities – for example, physical therapy, activity modification, injections – are often tried first, but minimally invasive surgery can be an option for many degenerative conditions. “Is it something that will get better without surgery or will surgery give them good relief early? It comes down to weighing minimally invasive surgery against the conservative options. Conversely, for someone who might have three or four segments involved, minimally invasive surgery may not be right and we have to discuss other options.”
Minimally invasive surgery may be indicated for herniated disks (although, according to Dr. Phillips, most herniated disks get better without surgical intervention), lumbar stenosis, spinal deformities and infections, and vertebral compression fractures. Minimally invasive spinal fusions are also possible now for patients with traumatic injuries. When necessary, rods and screws, or bone grafts and spacer cages, can be placed through very small skin incisions without cutting or dissecting underlying muscle.
Many people, acknowledges Dr. Phillips, resist spine surgery because of the specter of needing future surgeries. “There is certainly the fear that the more surgery you do on somebody’s back, the more risk they are going to have for long-term complications,” he says. “Yet, this is a useful surgery for many. It’s not a surgery that is going to cause injury to a lot of structures and change a lot of the body’s biomechanics. Most people with minimally invasive spine surgery will be able to go through the rest of their lives without fear of requiring more surgeries. For a person in their twenties, with a herniated disk, you’re not going to want a big surgery and it’s going to let you get back to work or playing sports.
“For an older person, it will decrease their pain and the numbness down their legs. Not getting the surgery early can be a disservice. They walk a block or half a block and their legs start burning and they feel they need to sit down. Their lives just start collapsing under them. Instead, with all the complications and half-measured treatments they often end up with sedating medications that can increase the risk of falls, constipation and delirium. With the surgery, a majority get better and the likelihood they are going to need something down the road is pretty low.”
That certainly was the case for Sylvia, the baker of Italian delicacies. “A month after the surgery she was back to her normal life,” says Dr. Phillips. “One day she came into the office with friends, and they were all talking about what she could do now. She was back to cooking up a storm and going out with friends again. They wanted me to know just how amazing that was.”