Cervical Spondylitic Myelopathy

Our guest author today is Orthopaedic & Spine Center’s Managing Partner, Dr Jeffrey R. Carlson, MD. Dr Carlson is a Harvard trained spine surgeon and in addition to his duties with OSC, he is also Chief of Surgery at Bon Secours Mary Immaculate Hospital in Newport News, VA.

As an Orthopaedic Specialist, I treat people with Arthritis every day.  However, Arthritis in the neck has some very unique properties.  There are 2 specific places in the neck that have cartilage which can degenerate with arthritis.  One of those places is in the small joints in the back of the neck called “facet joints”.  These small joints act as stabilizers in the spine when the bones move.  They control the movement of the neck, so that the bones do not come apart.  The facet joint is made of 2 bones which are covered in cartilage.  The cartilage allows the bones to move smoothly and without pain.  When arthritis begins to affect the surface of the cartilage, the once smooth motion becomes rough and painful.  This pain will cause the patient to want to limit the motion in the neck.  The second place that arthritis of the neck can be a problem is in the spinal discs.  These discs are composed of cartilage, provide the separation between the vertebral bones and allow some cushioning between the spine bones or vertebrae.   As these discs wear out, the “cushion” is degraded and the motion in the neck can become painful.    The discs are also closely associated with the nerves.  As the disc loses its height, a bulge of the disc may develop.  This bulge can pinch the nerves that affect the arms or the press on the spinal cord that can affect the nerves to the rest of the body, causing pain, weakness or numbness.

spine surgeon dr jeffrey carlson md

Dr Jeffrey Carlson MD

Specific compression of the spinal cord is called myelopathy.  The spinal cord is the extension of the nerves from the brain to the rest of the body.  These nerves are very sensitive when they are still part of the spinal cord as in the neck and upper back. This compression is not found in the lower back when disc herniations occur because the spinal cord does not extend all the way through the length of the spine.   Because the spinal cord carries all of these more central nerves, compression of the spinal cord can lead to global difficulties.   There may be difficulty with fastening buttons, handwriting and ultimately walking.  Some extreme pressure on the spine cord can lead to paralysis.

Spinal cord compression in the cervical spine can have significant implications on a patient’s function.  This has been shown in many studies, that spinal cord compression will continue to cause difficulties until the compression is relieved.  Unfortunately, surgery is the only way to relieve this pressure.   In general , patients and surgeons try to use surgery as the last resort, but with compression on the spinal cord the best treatment is surgery.

A recent study looked at the outcomes of surgical intervention in patients with spinal cord compression.  The CSM-North America trial looked at the surgical treatment in patients with spinal cord compression from arthritis.  It has shown that patients with spinal cord compression are best-treated early in the disease process.  Those patients that had difficulty walking from long-standing disease were less likely to get better.  Those patients that were older and were smokers also had less improvement in their symptoms.  The best treatment is surgery to remove the pressure on the spinal cord before permanent damage is done.  Surgery will also prevent worsening of the disease which will protect patients from having spinal cord injury later.  Spinal cord injury related to arthritic compression may not be reversible, but without surgery there is no chance for it to improve, so it is best to remove the pressure from the nerve roots and spinal cord to allow them the optimal environment to heal.

Dr. Jeffrey R. Carlson is a Harvard Orthopaedic/Neurosurgical Spine Fellow and is Chief-of-Surgery at Bon Secours Mary Immaculate Hospital in Newport News, VA.  He is the Managing Partner of Orthopaedic and Spine Center in Newport News, VA.  For more information or for an appointment, contact OSC at 757-596-1900 or go to www.osc-ortho.com.

Facet Joint Cysts

by Jeffrey R. Carlson, MD

Managing Partner and SPine Surgeon at Orthopaedic & Spine Center of Virginia

The spine is divided into motion segments that include the vertebral bones and the discs.  A spinal segment is comprised of the two vertebral body bones and the intervening disc.   The discs are the pads between the bones and allow the bones to move on each other.   Another important portion of the boney anatomy is the facet joint.  These small joints are on the back portion of the bones that provide the stability for the bones to be able to move and rotate, without becoming separated from the discs.  As the facet joints move, the cartilage in these joints will wear or degenerate.   This arthritis in the facet joint can be caused by the natural wear of the joint or by an injury that has damaged the joint.

All of our joints that have a cartilage surface and also have a lubricating fluid called synovial fluid.   The fluid acts to decrease the friction on the cartilage and allow the joints to move more smoothly. In the presence of arthritis, our joints will increase the production of synovial fluid.  This excess fluid can help smooth the roughness in the joint a bit more, but may also decrease the motion in the joint.  The joint itself can only hold a certain amount of fluid, so as the fluid increases in the joint, the soft-tissues around the joint will become tight like balloon being filled with water.  There are times when the fluid leaks out of the joint due to the pressure.   If the tissue on the outside of the joint cannot hold the fluid, small holes may develop and allow the fluid to collect in small pockets just outside of the joint.  This collection of fluid is called a cyst.  These are benign collections of fluid, although some patients feel concern when a cyst is mentioned.

Because the facet joints are next to the nerves in the spine, cysts that form around an arthritic facet joint may press on the nerves.  The nerve pressure can cause pain along the course of the nerve.  This will cause pain in the arm or leg even though the nerve that is being pinched is in the neck or lower back.  These cysts may also form towards the central portion of the spinal canal.  If the cyst becomes large enough, it can fill enough of the spinal canal to cause compression on all of the spinal nerves and cause pain in both of the arms or legs.  This spinal canal compression is called spinal stenosis.  Continued pressure on the nerves can be painful as well as limit the function of the nerve and lead to weakness in the arms or legs.  The spinal stenosis may also cause difficulty walking or in handwriting.

The nerve compression, pain and loss of function is usually what brings patients to see an orthopaedic spine specialist.   After conducting a complete history and physical, the MRI scan is the way to diagnose the problem in the spine and visualize the size and extent of the nerve compression.  Unlike other nerve compression from a disc herniation or bone spur, the cyst can get bigger or smaller in relation to the amount of fluid in the cyst.  This can lead to the nerve symptoms to be worse or better within a period of time.

The treatment options are somewhat limited for facet cysts.  Some attempts have been made at draining the cysts and injecting cortisone.  This has a small chance of relieving the nerve compression for a short period of time.  As this method does not change the underlying arthritis that has caused the cyst, the cyst will re-fill with fluid as the joint continues to make synovial fluid to ease the joint roughness.  Unfortunately, the only way to effectively treat the cyst is to surgically remove the tissue that creates the envelope for the fluid and then fix the underlying arthritis is by stopping the motion at the facet joint.  In order to remove the pressure from the nerve and the cyst material has to be extracted from the spinal canal.  This is done through a laminectomy.   A fusion of the joint is done so that it no longer moves.  When the joint stops moving, it will not need to make the synovial fluid which caused the cyst, which then pressed on the nerve(s).  Because it is the mechanical pressure that causes the nerve pain, this procedure works very well to relieve the pain and accompanying loss of function and strength.

If you are found to have a facet joint cyst, it is best to discuss your options with a fellowship-trained spine surgeon to get all the needed information to make an informed decision.

Dr. Jeffrey R. Carlson is a Fellowship-trained, Board-certified, Orthopaedic Spine Specialist who practices at Orthopaedic & Spine Center in Newport News, VA.  Dr. Carlson was recently named a “2012 Top Doc” in a physician survey conducted by Hampton Roads Magazine.  For more information about Dr. Carlson and his practice, go to www.osc-ortho.com .  Check out the Patient Testimonials posted by Dr. Carlson’s patients.  For an appointment, please call 757-596-1900.

 

 

 

New Technologies For Orthopaedic Surgery: ROBODOC

by Boyd W. Haynes III, MD of OSC Newport News VA

Every day, new technologies are being developed to improve orthopaedic surgery, to help the surgeon be more time-efficient or accurate during procedures.  Even though millions of dollars may be spent marketing a new surgical technology to hospitals and physicians, not all new developments are beneficial to the surgeon or the patient.   As the patient, how do you know what surgical technologies are good and which are mostly marketing hype?  In this article, I will discuss the new technology, ROBODOC, and highlight its benefits and its disadvantages to you the patient and to me, the orthopaedic surgeon.

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ROBODOC was developed by the Curexo Technology Corporation as a robotic, computer-assisted, surgical assistive device for orthopaedic surgeons to use during hip replacement surgery.  With its beginning development phase starting in 1986, it was first used in an actual patient surgery in 1992 during FDA trials.  The ROBODOC systems subsequently received FDA approval for use in the United States for Hip Replacement in 2008.  (The knee replacement system is currently awaiting FDA approval).

The system comes with computer software, called OrthoDoc, which allows the surgeon to plan the surgery, using a CT scan of the patient’s joint to be replaced.  The robotic arm is used to assist the surgeon with precisely “milling” or preparing the patient’s anatomy to receive the joint replacement implant.  The robotic arm makes the cuts, drill holes and finishes all of the bone surfaces before implantation, based on the 3-D computer model of the patient’s anatomy, which was created from their pre-operative CT scan.

The planning of the surgery takes a fully-trained physician about 10-15 minutes for a hip replacement surgery, using the ORTHODOC computer software system.  Once FDA approval is obtained, knee replacement surgery can be planned in about 20-30 minutes using the software.  The surgeries themselves are said to average around 90 minutes, from incision to closing of the surgical site.  Part of the surgical time is used to register different points of the patient hip anatomy on the computer system, so that the technology can coordinate these points with the predetermined and coordinated surgical plan for the specific patient.

The benefits of using ROBODOC are that the computer and robotic technology  provide more accurate and reproducible results when doing total hip replacements, by relying more upon computer modeling and planning of the patient’s anatomy and not as much on the surgeon’s individual expertise.   The surgeon controls the operation from start to finish, however, and has the ultimate say in how the surgery is performed.  To date, the company website claims that over 24,000 of these ROBODOC surgeries have been done worldwide, with great results.

What are the benefits to the patient in having a surgery using ROBODOC technology?

  1. A surgical time of approximately 90 minutes (less anesthesia, less blood-loss and less time for infection to set in)
  2. Reduces the chance of surgical error.
  3. Reduces the risk of certain complications, such as pulmonary emboli, and intra-operative fractures
  4. The technology is very young but does offer some promise.

What are the benefits to the orthopaedic surgeon by using the ROBODOC and OrthoDoc technology?

  1. Ability to perform a simulated surgery using 3-D computer models anticipating possible complications
  2.  A surgical time of approximately 90 minutes (if the surgeon normally takes longer than 90 minutes doing a standard hip replacement )
  3. Can be used for both hip and knee replacements (if FDA approved)
  4. Can be used for joint revision surgeries
  5. Should be able to be used with any manufacturers implant system

What are some of the disadvantages of using ROBODOC technology in surgery?

  1. Much Greater Expense
  2. Longer incision
  3. Training time required of physician
  4. Finding a hospital that can purchase the technology
  5. No extensive data on outcomes or evidence of long-term success.
  6. Limited use of only certain hip components currently

The use of Robotics in Surgery is here, is expected to become more and more prevalent and the technology will get better and better.  Currently, RoboDoc and OrthoDoc are only available in limited, mostly metropolitan areas, the technology is very costly and, to date, has not proved its worth as a benefit to the patient, in my opinion.

Boyd W. Haynes III MD, is a Fellowship-trained, board-certified Sports Medicine Specialist who practices at Orthopaedic and Spine Center in Newport News, VA.  Dr. Haynes was recently named a “2012 Top Doc” in a physician survey completed by Hampton Roads Magazine.  Dr. Haynes welcomes you to learn more about him at www.osc-ortho.com and encourages you to make an appointment for a consult.

Ultrasound as a Diagnostic Tool in Orthopaedics

by Boyd W. Haynes III, MD

Orthopaedic & Spine Center, Newport News Virginia

Ultrasound has been used in medicine for many years. Ultrasound is the use of high frequency sound waves to create an image based on those sound waves traveling back to a receiver. In recent years, providers in the medical field have found additional uses for ultrasound technology. For many of the same reasons that ultrasound became popular years ago, its popularity has risen with orthopedic surgeons.

At Orthopaedic & Spine Center, we often use ultrasound to help guide needle placement as we administer steroid injections into an inflamed area. More accurate placement of injections likely results in improved effectiveness of an injection, and increased patient satisfaction. At OSC, we also use ultrasound as a diagnostic tool for certain conditions such as tendon and ligament injuries. We feel the gold standard of diagnostic tools for most orthopaedic conditions is the Magnetic Resonance Imaging (MRI), but ultrasound can be used as a powerful non-invasive tool in many soft tissue cases.

There are quite a few benefits to using ultrasound in our office to help diagnose patient issues.

  • Ultrasound can be done quickly and easily in the office. It doesn’t require a pre-authorization from the patient’s insurance company, and is a cost-effective addition to MRI.
  • Ultrasounds do not emit radiation, so ultrasound is a great alternative for patients with pacemakers or spinal cord stimulators. It can also be repeated numerous times without the concern for side effects.
  • Instant gratification – we don’t have to wait for an MRI report to determine what the problem is. We can have a “real-time” dynamic exam with ultrasound. In the span of one appointment, a patient can tell us what is hurting, we see the problem area, show it to the patient, and come up with a plan of care. The physician can watch the muscles and tendons move, allowing for excellent evaluation of the problem.
  • Diagnostic ultrasound helps us look deeper into some injuries to find the source of the pain; ultrasound may pick up very small tears that an MRI, CT scan, or X-rays might miss.
  • Diagnostic ultrasound is non-invasive and painless.

Common uses of ultrasound in an orthopaedic practice include:

  • Evaluation of tendon tears, such as the rotator cuff or Achilles tendon, and muscle tears
  • Charting the progress of tissue after surgery, or during the course of a non-operative treatment plan
  • Evaluation of fluid collections in joints, muscles, or bursae

Ultrasound is not replacing other diagnostic tools. For some injuries or conditions, an MRI, X-ray, or CT scan is most appropriate. We often elect to use ultrasound as a non-invasive diagnostic tool when we feel it would provide us the information we are seeking.

Boyd W. Haynes III, MD is a fellowship-trained, board certified Orthopaedic Specialist with Orthopaedic and Spine Center in Newport News, Virginia. Dr. Haynes’ practice is focused primarily on sports-related injuries and disorders. Call 757-596-1900 to make an appointment. Visit www.osc-ortho.com to learn more about OSC and Dr. Haynes.

 

Smoking and Back Surgery

Orthopaedic & Spine Center’s Managing Partner, Dr Jeffrey Carlson MD

On the Impact of Smoking and Spinal Procedures

As a Spine Surgeon, the standard instructions I give to patients when preparing for spinal surgery always includes telling them to stop taking their blood thinners (including ibuprofen, naproxen and aspirin), not to eat or drink after midnight the day of their surgery and to stop smoking before and after surgery.  Most patients generally understand the reasoning for stopping the blood thinners, i.e., they don’t want to lose more blood during their surgery, and that eating before anesthesia can lead to vomiting and possible pneumonia due to the chance of inhaling stomach contents.  However, getting patients to understand the critical reasons for smoking cessation before and after surgery and subsequently, getting a patient to then stop smoking, presents a much greater obstacle for the Spine Surgeon to overcome.

It is commonly known that smoking has deleterious effects on the lungs.  Lungs that do not function properly, for any reason, put the surgical patient at a higher risk for complications from anesthesia.  Anesthesia puts the body to “sleep” so that the pain from surgery will not be felt.  As a result, the brain is often affected and basic autonomic body functions, such as breathing, are depressed and must be monitored during surgery.  For any patient that is to undergo anesthesia for surgery, their lungs need to be at peak performance.  Those patients who smoke should consider stopping smoking for 3 months prior to their surgery to give the lungs a chance to clear out any of the residual substances deposited from smoking.

It is well-documented that smoking increases back pain.  There are multiple studies that have shown smoking to increase the number of back pain events, as well as the severity of those events.  Those patients that are undergoing back (spine) surgery obviously have a back problem.   Smoking will increase the back pain associated with the diagnosis predicating the surgery, as well as increase the pain related to and after the surgical procedure.

The crucial reason we ask patients to stop smoking after surgery is to allow the surgery the best chance of success. We know that smoking causes our blood to carry less oxygen.  The oxygen is what our body needs to survive and most importantly, heal after surgery.  In the smoking population, there is a higher risk of the surgical procedure not healing.  There are some very good studies which look at the rate of healing after spinal fusion surgery.  One, in particular, from the journal SPINE (2000), follows 357 patients that needed to have lumbar (lower spine) spinal fusion surgery.  In this study, the patients were the same, except that some chose to continue smoking after surgery.  As a result, they found that 26.5% of the patients that continued to smoke after surgery did not heal their fusion, which is called a non-union.  A non-union not only leads to an increase in back pain, but also a failure of the surgery to improve the patient’s life by decreasing their pain.  The study also found that only 53% of patients that continued to smoke after surgery returned to their normal work, compared to a return-to- normal work rate of 75% for patients that quit smoking for 6 months after surgery.  This clearly shows the harmful effects of smoking on spinal fusion surgery and the effects on the patient’s work and lifestyle.

Prior to surgery, you must seriously consider the effects that smoking will have on the outcome of your surgery.  You should understand the real possibility of facing a follow-up surgery because your initial fusion surgery did not heal.  Discussing these issues with a fellowship-trained spine surgeon will help put your mind at ease for your upcoming surgery. There are many tools available to help you quit smoking.  Partnering with your specialist to achieve a great outcome puts you in control of your recovery.

Dr. Jeffrey R. Carlson is a fellowship-trained, Board-certified Orthopaedic Spine Specialist who practices at Orthopaedic & Spine Center in Newport News, VA.  Dr. Carlson is Chief-of-Surgery at Bon Secours Mary Immaculate Hospital in Newport News, VA.  For more information about Dr. Carlson or OSC, go to www.osc-ortho.com or call 757-596-1900.