This episode is entitled “Lumbar spinal surgery?”, and it will answer the questions:
- Should you have lumbar spinal surgery?
- What could go wrong?
- What does the surgery involve?
- How long does rehabilitation take?
- Who is most and least likely to benefit from lumbar spinal surgery?
- How to choose a spinal surgeon?
Surgeons are much more confident and capable historically in operating within the spine itself. Manipulating span nerves, operating the lesions in the spinal cord, and in a training that’s very advantageous. As a young trainee in surgery, we started getting our training in spine surgery from very early stage from the first or second year you had training. On the other side, however, the orthopedic surgeons are much more capable in what we rolled. This guy was instrumentation of body, so that different media with acute replacements, knee replacements, eventually other parts of the body. And then, historically they’re much more geared into instrumenting the spine, which is unstable for whatever reason when terror, scoliosis, infection or malignant. It’s a very evolving field, the issue of spine surgery, although I’m sure that if you ask three surgeons will give you three different opinions. It’s an issue of balancing risks and expectations. You have someone with an unstable spine that needs a very complex instrumentation, which may make them better, but then may make them spend six months recuperating. I do performance panel stabiliation in various levels, a group of patients, and the first thing I say to them is that their operation is going to be very lengthy. And interestingly, the first thing he said to me after was “my leg pain is better but my back is still weak”. The alternative is that with modern pharmacotherapy, modern physical therapy, you may all with the introduction of steroid injections, you may lose your balance that provides the quality of life that individual needs, because that’s a vague broad category. What are some of the big, just want a way of walking to the newspaper shop and walking the dogs and spend those time resting, which I think is a very big sense of the were of living the life. And some people [inaudible] at the age of 80. I don’t believe in the division between the neurosurgical perspective of spinal surgery and the orthopedic standpoint, would you emulate the spinal? It’s just a mechanical component, is methodology in terms of making the quality of life better. A way of concentrating on the needs of the individual patient. I’m a very conservative surgeon, but I stabilize the gender spine obligations.
What are the most common lumbar spinal procedures for someone who has a prolapsed disc, which is causing nerve compression, which demonstrated on MRI? We’ve accepted that the symptoms pretty much mint the match, the picture that you see on an MRI, what’s likely to happen to that person, given that there’s a lot of consultation going on about the pros and cons of surgery?
A lumbar disc prolapse would present with neurogenic pain. We categorize the patients in three groups. You’ve got the uncommon scenario of the [inaudible] syndrome with the very large disc prolapse causing numbness in the private areas, which generally is operated on an emergency basis. You’ve got the individual that has sciatica, which remains very resembling for more than six to eight weeks despite optimum for monotherapy and physical therapy. For that sort of group of patients, the decisions between surgery or STD injection is still the injection has a much more modest long-term effectiveness, generally up to 30 or 40%. Surgery has a much higher chance of success, about 90%, but these are surgeries that the actual surgical trauma forces the patient to be very cautious for six to eight weeks afterwards. There’s a small risk of this coming out again, except for the surgery, but on 10%. And there’s a small risk of infection. What people dread, which use the development or a major catastrophe with weakness or numbness or lack of sensation as a result of the surgery from the damaged nerve, thankfully is very, very uncommon. That’s sudden worth knowing. As an individual, I always tried to myself on the patient’s shoes. I’m 55 years old. Some of my patients are younger than me. Some of them are older, but if five minutes sake, I would have CVSA Africa for more than six to eight weeks making a nav to work, do my job. And if I was talking about injection with very short-term effectiveness, and I know that my clinical progress, we being perfectly another six weeks, then it will accept the operation. Knowing that within two weeks it will be much better.
Thankfully, these are the second group of patients. And third group of patients are those who have persistent pain for several months and they are resisted the option of surgery because naturally don’t want to introduce any norm into management. And that’s a separate type of infection. The challenge with will, but these people esteem pain and eventually we do operate in them. It’s very interesting because despite the fact that the surgery doesn’t have much of randomized evidence, [inaudible] high quality information to support, but we do in spinal surgery, we do have randomized anythings that those potentially support what I’m just saying. That surgery is aimed to people who want to get better, faster, understanding that even if they don’t have the operation, there’s a quite good life lag with that in the long term, they may get better. Nevertheless.
This is the journey that the three brothers
Categories that I treat English better say I’ve got from it. These prolapse, which as you suspected, is the commonest scenario that I’m involved with.
Can you describe the surgery on an anatomical level?
We have the patient lying down. We do an incision in the midline and we feel the bone in the spine, which I call the sponge processes, these bones protruding from the spine. then we dissect the muscle from the side. As we do that at the back of the spine, there is a gap between the bones that we normally dissect. And we enlarge. We’re very fortunate that we use a very sophisticated microscope use procedure, which, and largest assessment fee almost 50 times and illumination is truly amazing. On a beam to identify the tissues is exceptionally good. We remove that part of the tissue, do the bones, then identify the node, which is squashed. We manipulate it sideways, and then it would move the part of the disc, which is squashing it.
When you say you remove that disc, what’s it like? What kind of substance is it?
There’s like, they hard rubber by the actual substance of abuse, which is most likely compressing. The nerve is very soft, and this is what we would call the nucleus pulposus [inaudible] so it’s presumed or I don’t know, but over time, let’s say there’s a fresh prolapse. Let’s say it’s happened in the last week. Will the consistency of that tissue, that nuclear material, will it change over weeks and months?
Generally? It probably does. And that’s why not infrequently. You do a scan acutely after the onset of pain where you can see that big discount, you’re going to be discounted for six months and then these can be able to get less. Although we never operated in the same patient twice to make comparisons and take into account what we find on MRI scans, that there is no doubt that in their significant proportion of individuals, the consistency, the signs in the appearance chronologically change over time.
I always say to patients: “once that stuff’s come out of the disc, it’s never going back in, but your immune system will attack it and break it down over time”. This is known as resorption. It’s not really an accurate term as options. Not that as much.
I think it is. I use the temperature option frequently when patients ask me whether these can shrink of a dam. [inaudible] solution. I use the [inaudible] the tissue, which is swollen and gradually the constituents shrinks continuously. We don’t necessarily go through the whole of the surface that the aggressed form, but the actual tissue shrinks spontaneously all the time. It’s been difficult to know what happens because new scar tissue may fall. And then you may find that the actual Antabuse reformed as well. And kind of by the question, sometimes we, we operate when we do redo the skeptic is for example, where you have removed the disc, you left a hole in the surface. That generally is the scar tissue, but let’s say after several years, the disc content can come out. And where do you operate? The actual unused doesn’t look much different to the idea of a discus never been operated. It’s the issue of resorption. Although I don’t think we’ve got a logical support to be dogmatic about it. I think it does. And I wouldn’t be surprised if the aneurysm itself heals. Certainly with, with surgery in Renu operations, we do see that.
If you’ve seen someone who has either recent prolapse versus someone who has an old one, can you see any difference in the surface of the annulus?
In general, you didn’t display, the owners would be much more stretched and weakened, whereas the chronic prolapse, you didn’t display the dishes to be more hard. That is black and white, but that’s generally
You’ve been disadvantaged. That’s natural scar tissue formation forming over the defect and the annulus.
I always say to patients is that they will, in the natural history of these things is hopefully the discourse Hugo over. But that takes time and inflammation is the first stage of that process
In general. I totally agree with what you’re saying. That’s, that’s my interpretation on the evolution of the pathology.
You’ve gone into your remove that piece of prolapsed material. And then what happens, what kind of unit
Then you close the wound there, but coming back, where was it earlier about the fact that we leave a small hole in the arm you lose, these is relevant because that whole, if you like reduces the resistance of the disc to allow whatever left in the disc space, protruding a game and causing you to cut it with these four laps.
Is there ever any attempt to patch on that
They used to be, they used to be one of the most fascinating thing about surgery is that the greatest breakthroughs in my trade other 40 years ago, really, no matter how much we want to modernize what we do find new of making surgery, less risky and more effective and long term. I don’t believe that we’ve achieved that sort of migrant diskectomy that we do. I perform my patients was introduced over 50 years ago. And as you have you do too, sometimes people try to patch the hole with what materials by sometimes I’ve tried to use artificial discs to cover the gap. Sometimes try to enforce the area with other materials to use the school of mechanical back pain. Sometimes they inject steroids. But the bottom line is that if I had say, I think anyone operation, I would rather have the impression that it was done for the first time, 50 years ago. And I don’t think that there’s any other alternative currently that has Jen’s periodic theme from a technical standpoint. But
Sometimes I have questions, particularly from people from North America who talk about disc replacements. But what you’re seeing is in terms of the evidence that those are, is fascinating broadly, no more effective,
The way surgeons thinking there. I think we shouldn’t stereotype, but the, I can understand the play, the public stereotypes when they describe surgeons as not being as deep in our thought process. When we, we, we, we, we make decisions on what should be done about the particular scenario, but I’m very fortunate that as I said, you have been through lots of changes in that philosophy. I remember 23 years ago, I was in the most major and your surgical meeting in new Orleans and people were debating as to whether the data was about cervical surgery, whether they should just fuse it. These books would fuse in plate the plate in front of me. And they were saying all the way, if you fuse it, the chance of success is 90%. If you played, it is 92%, can we do even better?
And they were arguing that these 2% difference was important because I, myself, the level of, Obviously the option called an ignorance, which is ignorant and the barking, when the paleo sense, she was just concentrating on their own. part of what you do, because if we accept that the healing process or the human body is not, or do you need that surgery is remove the inflammation that cause pain that the body can do it. There are exceptions obviously, but I don’t think that any, new development in the techniques that we are employing to open, this is generally severe, the bugs we started getting do. For example, if you’ve used a go, I tried to learn how to do the India scopic diskectomy, which has the advantage of allowing the individual patient to go home much earlier. But I have to say it was technically more risky procedure. I don’t want them to create an impression which is riskier, attempt to make the patient how has shorter recovery? The recovery is not the place to do studies the procedures.
And to stop it, meaning you’re not opening somebody up now we’re going through a Small hole. X as you have. . [inaudible] You’ve closed the person back up after that, given that there must be significant variations, particularly age related
How long does rehabilitation take
In terms of pain, is quite soon. The majority of patients would feel better in terms of the gun within 48 hours. And most of the people will feel better within six weeks. The, the back pain is not insignificant. Sometimes I’ll tell them if you know that they’ve been having pulled muscles sometimes in Kik. Bye bye. [inaudible] the, the extent of their sex. Assuming the patient is not in line with the intention of pain, you can do very small incision and the patient may have more stiffness and pain than something that big incision. You cannot predict how much missing pain and disqualify individual, how necessitating patient based on the actual operation itself. Obviously you’re always trying to dissect only the tissue. Then you have to explore that more. People, we find difficult to, before the normal group of the spine for several weeks, I can see it with myself because one of the commoners causes of back pain on people of our age is classic joint. [inaudible] myself. Sometimes when I operate under the microscope with the particular Institute posture my back, what I say very uncomfortable, but I know do that discomfort that can highly twisting my back. Patients after back surgery will have the same type of stiffness and discomfort, which sentence within days or weeks.
What are the main factors that determine outcomes in spinal surgery?
Who is most and least likely to benefit from lumbar spinal surgery
Patients whose pain he’s of neurogenic origin, eye inflammation, and nerve, and from the clinical history and examination, the causes of that pain seem to be directly related to either location of the nerve. For example, patients who have more pain when they seat, when they get up from sitting position whose pain improves, when the light bed whose pain gets better, when you raise their leg, who find that particular positions cause more pain or less pain, that’s what we call the mechanical association in your genuine pain. Those people generally have a very high chance of getting better because from the history of the seams particular positions in culture, more than addiction, if you take away the whole meditation, the judgment and flame getting better are much higher.
And obviously nothing. Medicine is like a wait. We do know that many people have no symptoms do have these barges on the scan. The scan cannot give us the answer as to whether the cause would be used with this parts we see on the scan. Sometimes the nerve maybe boost from the pressure from the, so even if you take out, if you remove the pressure, then bruising can cause persistent pain, sometimes do the operation. You have to manipulate the nerve a little bit to extra pay that these compared to manipulation can cause potentially damaged the nerve. There are these, these pitfalls got nodes, beg me say that the Johns of success was surgery on the patient. And the fact that you treat him successful is a hundred percent. I said, my pictures of debating will have the chance to do 80, 90% improving significantly.
And that type of scenario. Now the failed back syndrome is a very, is a big complex scenario. I think historically part of the reason why you have failed back surgery was because clinicians would see a disc on a scan and assume that, that these cause pain, which we know is not true. Some of the patients who failed back surgery from say 20 years ago, I think that scenario is relevant. And then we do know now you said that you can see it, this may not because in symptoms nowadays, the majority of patients that we see with Facebook seem to think, we’ll have to add a note that many, we do have some patients that you can do an operation CNX, one scan and still be in residual pain that, that I wouldn’t cause a call as failed back surgery would excuse the individual to come in and we check and of walk through some morphine and, and has a totally horrible life.
That’s where that cause on failed back surgery, one of the reasons that people thought of failed back surgery, you scores because of scar tissue, that was something that we used to describe a patient since sort of warn them about when we’re consenting them 20 years ago, very, very frequently, but I don’t see much pain nowadays from, from, from scar tissue, we have to say the most likely failure of this specialist is the, these that you operate, perhaps it wasn’t causing the pain and the other possibilities that are new pathic medication may be more effective. The thing people think of abandoned pregabalin [inaudible] do you find them normally effective? We either have less or fail maximum syndrome days or more effective ways of treating it. And it sounds like from what I’m reading correctly between the lines part, part of that may be that 20 years ago, there was more of an inclination to treat the scan or the x-rays were treating patients.
In terms of helping someone to make a decision around whether to go for surgery or not, or there may not be hard and fast rules, but other things that are clearly, we know what red flags are, but the person listening to this may not. And I think you mentioned earlier occurred at Aquinas syndrome and certainly we stress and intake form in the clinic. We ask all these questions. Do you have any problems, recent problems with waterworks, bowels, any numbness in your pelvic floor? The bit that you sit on, if you’re on a saddle, all these kinds of red flag questions, but excluding those, are other, should I rush to have surgery now? Is there a window of opportunity?
No, I don’t think so.
Even if I defer it by six months, if I’m still in as much beam in six months as I am now, it’s not that I’ve missed, I’ve not reduced the chances that I’m getting successful.
A group of surgeons who claim that if you don’t have an operation two years from the onset to say Africa, the charge of successes is being modest. That’s not my personal experience. To see patients are sometimes half had paper, more than two years, I still operate on them and they could get better. One of the important points that individuals should be aware of is that the pressure that the disc exerts on the nerve, there’s not necessarily damage with the only exception, the coordinate quiet. I will mention if you have a note which is quashed for three months, six months, nine months, when you compress, it is not more likely to be damaged if you wait for nine months. And that’s why I don’t think that these speaking, speaking opportunities or the individual sufferer, the important thing is how the pathology and the thinking syndrome affects his individual’s quality of life.
I put myself in the patient’s shoes, pallets say Africa, that prohibits me from doing my job and to find out that there hasn’t been any improvement over thing, just a six to eight weeks and try and implement a loose painkillers, potentially still injection. And then I know that the likelihood is it’s, my pain would last for six months before it gets better, then I would be giving up an abrasion, knowing that the main issue about surgery is that a corporation or when you’ve just described it. I think that is something which not an estimate. And then, and that’s what I said, it’d be cool. Let’s say, are they still working or, cannot take, let’s say six to eight weeks of work without them being a major inconvenience, but they’re normal. There are no right or wrong rules.
I get that. Just comes down to the individual and this discussion with the individual, weighing the pros and cons.
You shouldn’t sound surprising. You spend more time discussing with the visual about the oppression and actually performing it. The lead the time it takes for me to be executed from the beginning of the end zone 50 meetings. When I consult patients, it takes me between 30 minutes and 40 minutes on initial consultation and 20 minutes on the consultation when the sand, the con the consent, the next minute longer describing what to expect and actually doing the impression itself.
And as a smaller side, as I mentioned Mr. [inaudible], you understand, I do share at least one patient, and I can confirm that to the lady in question and did say that you have a tremendous way about you in putting the patient at ease and spending as much time as she felt was necessary to discuss the pros and cons. And I think that’s, that’s tremendous, rather than just saying. We’ll send you on vacation, but it comes with experience and age, because one of the things you realize when you’ve been a concern for almost 20 years, is that what people understandably worry about is unexpected problems. They do things that people find difficult to accept when correctly is something that they’re unaware of or expecting more from an abrasion that oppression can offer. If you say to the vision, we find that we find that a good bit of let’s say, facet, joint pain. You haven’t told them about that, then understandably, they will be very awarded. Or if you have a bit of numbness in the thighs from BitSight compression on the ladder of tenors, nerve of the thigh, from the positioning, then warring, or what, if you tell them that there’ll be a hundred percent better, that would water. It’s not just the empathy that obviously we all should have and have, but they’re eat.
They’re all practical aspects about every surgery. We tend to ignore us or the estimate, in the following, major cases, not really just one surgeon, I’m just saying in terms of the consenting process, although certainly this will be brief what we are talking about. I think it’s the most important part of what we do. I think if you see an operation is in YouTube, you’d be amazed how the patient can, can withstand the sexual trauma, but the actual operation itself. The steps of Vegas straight forward with microscope, the visualization, but the, he is very interesting to do, to accept him, believes that the gentleman had canceled. He’s trying to repeat the device. Each individual patient is different. We know we have 10 patients having the same type of pain, but the effect of that pain, these 10 different people is going to be totally different. You’re very caring about your patient, but he is a very important part of what we do. Just making sure that people understand what the expectancy of the surgery. You should be able to explain people. What do you do? Because the anatomy is very clear. You don’t do a very complicated endocrinal operation and brainstem.
How to choose a spinal surgeon
I’m very fortunate to have the chance to the trainer came down. And I still believe that the training in this country is of the highest quality. And as I said, I’ve been exposed to the North American process as well. And in general, the quality of, of, of surgery and medical services in the United Kingdom is excellent. My family with in spine surgery, any of my colleagues in Scotland would be capable in disabling the next one.
It sounds like I can pin you down in terms of good, bad, and indifferent, hopefully not many bad, but there’s probably the, the odd one. I just wondered for me, what I would look for in a, in any surgeon, especially is the communication is, as you said, taking the time to make sure I didn’t feel rushed and that I was making a very well-informed decision in collaboration and looking for you experience and your input, but ultimately feeling like I was the one making the decision.
Patients have the ability to discern that they, I’m not talking about having spine surgery. The most difficult on occasions communications with individuals is when I perform into claimant procedures to meet the differences between the kind of procedures, procedures that inspired these groups are there in the form of damaging a nerve or causing exceptionally small, thankfully worsen, independent surgery. The risk of having complications is not insignificant. And then it’s very eyeopening. When you explain clearly to individuals, whether it’s they’re much more willing to accept them, because it makes sense essentially. Communication is very important that the collaborative with you, however, I do believe that it should also be sort of a company by the appropriate expertise. I have to confess that we’re very lucky living in Scotland. The quality of the health services in Scotland, in the UK is an exception, high quality. Naturally the difficulty that the service has is that as at the beginning where we’re living longer with more expectations. The access to the services is unfortunately an issue. But once you reach the services that the delivery of the services, I don’t think that anybody will argue they high quality.
We talked perhaps off Mike about degenerative change and the spine, and this is a term that causes people, all sorts of anxieties. You always said, I have a warned spine, degenerative changes and the impression, not just impression, but we know this from the research. When we start to use these kinds of terms, people often then catastrophize, do you think that’s the beginning of the end for them? And then it’s a one way track, but from your experience, you actually get to see inside people’s spines. Should we be concerned about degeneration in the spine?
Not at all, if there’s one thing that the listeners should take from our discussion is that they shouldn’t be worried at all. If they would have a scan which shows Wellington degeneration and a whole page of toppling comprehensible terms, it means nothing. You can be mild and writer. I can assure them that the most successful professional athletes have degeneration despite probably more than the average individual of the age and their, Hey, it’s probably the, the problem with, with, with, with the developing technology. We’re both started out training when the MRI scan was introduced and then our ability to identify even my nude body has been unique. And it took us 10 years to realize that it doesn’t matter whether you see 10 years to disseminated to the rest of the nonspecialists another 20 years and disseminated to the public. Having weathered them, the spine means nothing. Actually, everybody does what they have. Despite I don’t think that anybody at the age of 50 will have a bit of stiffness in the morning and bit of difficulty putting on the socks from time to time. But the challenges of VAT feature causing progressive problems is not true. That’s some nation. We can think of any degeneration the way we think of gray here. And I’ve got lots of weepers.
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