Webinar Episode 5. August 2023
Welcome to the fifth live webinar with Joel Proskewitz and Jessica Aidlen MD.
The questions addressed and their respective time stamps were as follows:
00:07 - What’s happening in the world of spine surgery? Pre and post operative rehabilitation developments. Exciting technology to place screws and cages. Less invasive techniques and the maintenance of soft tissues and the importance for patient recovery.
04:10 - Open versus minimally invasive Closed procedures.
05:05 - Motion preservation techniques. Cervical and lumbar spine differences. Longevity data for cervical disc replacement is better than lumbar.
08:45 - I experienced a disc extrusion at L5/S1 late March 2022 (approximately 16 months ago) with back pain and sciatica on the right side. MRI 20/5/22 showed 8mm AP extrusion with contact and displacement of traversing S1 nerve root. 12 months post injury my neurosurgeon was recommending a discectomy, but I continued with conservative treatment (McGills big 3 and regular walking). Recovery has been very slow but is continuing with more subtle improvements of late eg sleeping on the affected right side gradually improved and has only recently become pain free after having to avoid this posture as much as possible. However, while walking I am still getting low level pain in the right buttock and sciatica in either the calf, back of knee or the back of the lower thigh. My question is would surgery at this late stage be likely to resolve these remaining symptoms or will more time hopefully achieve the result I’m looking for?
Disc herniation data shows extruded disc fragments resolve themselves and this can sometimes be up to 2 years. However persistent symptoms, severe pain and / or neurological deficits may mean an operation could be considered. Nerve recovering does tend to lag behind even when fully decompressed.
15:10 - Two surgeries on L5 S1, a micro discectomy and an endoscopic discectomy. I’ve been left with internal scarring close to the nerve, possibly still some disc material there too not removed due to limited field of vision with the endoscopic surgery. I have regular flare ups of sciatic type pain, not enough to debilitate but makes it hard to relax and / or concentrate. Would a full open surgery improve matters or just likely make things worse? And I know, it probably depends on many factors.
Research suggests endoscopic disc surgeries can have higher re-operation rates.
17:30 - Fibrotic scaring and what can be done? Can we assume it’s the scaring causing pain? Delineating pain measures and you can’t just assume this is scaring causing the problem.
19:30 - In a patient with persistent radicular pain with a radiologically successful lumbar fusion, does an EMG provide reliable diagnostic information?
Diagnosing the pain generator is key.
23:15 - Why do many spinal surgeons typically refuse to operate on a patient if he/she does not have leg pain?
Leg pain and back pain differences.
25:20 - Axial / intractable back pain and the way forward? Ultimate goals for the patient. Body alignment etc.
27:40 - Can sliders replace worn discs?
Inter body cages / shims (spacers) with some examples of when relevant. Spacers and 360 degree possibilities for the patient. Successful uses in scoliosis and re-alignment needs. The Lateral Inter Body Fusion.
32:10 - In the last webinar, you spoke about recognizing patterns based on the location, type, and characteristics of pain. Could you please reiterate the most indicative pain patterns for a patient experiencing discogenic issues, when there is no radiating symptoms present.
Recognising patterns for the patient experiencing discogenic issues when their is no radiating symptoms present. Sinuvertebral nerve, back pain and practical examples of pain inducing movements. The physical examination importance.
40:40 - Claustrophobic imaging options. Are the standing scans as good as laying?
42:06 - Clinical hyper mobility patients and surgery. A very challenging patient population and it is a spectrum.
45:00 - Why an EMG assessment and when. Chronic nerve change and denervation can be detected. An EMG tests the nerve conduction and denervation can mean there are active and ongoing changes to the nerve. This doesn’t necessarily mean you do not have nerve pain.
47:45 - Nerve root compression and the pain, pain and sensory systems and pain, sensory systems and weakness are a spectrum.
51:50 - Endoscopic procedure and adjacent level damage during a procedure.