Discectomy Pain

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Stu McGill’s Big 3

I first heard about Stu McGill on a podcast about the rehabilitation of high-performance athletes.  He was describing how some world class performers trained to get back into top form after injury.  He was reaching peak academic nerd-speak with ‘muscle activation’ this, ‘motor pattern development’ that, when he mentioned his “Big 3” for the everyday back pain sufferer.  My ears perked up as he distilled all physio stretches into just three simple exercises.

As a professor and researcher at the university of Waterloo (Canada), McGill is an expert in the field.  At his Spine Biomechanics Laboratory, he focuses on a few core objectives involving how the back functions, how it gets hurt, and how to fix it and prevent further injury.

The four quadrants of muscles that support the spine are the rectus abdominus at the front, the obliques at the sides and the extensors at the back .  As McGill states, ‘true spine stability is achieved with a “balanced” stiffening from the entire musculature’ within the load tolerance (pain threshold) of each individual.  The “Big Three” exercises strengthen these muscle groups and help to increase endurance during lifting, pushing or pulling.

Remember to never over-exert yourself doing these movements and if pain persists, please check with your physiotherapist to ensure that proper form is being used.

Stu McGill’s ‘Big 3’ Exercises 

1.  Modified Curl-Up
Laying on  your back, one knee is bent and one knee straight. Your hands are placed under the arch of your lower back and begin by bracing your abdominal muscles and bearing down through your belly. While keeping this brace, breath in and a breath out. With your spine in your neck and back joined together, pick a spot on the ceiling and focus your gaze there, lift your shoulder blades about 30° off the floor and slowly return to the start position.

2.  Side Bridge
Laying on your side, prop yourself up on your elbow with your elbow directly under your shoulder to avoid straining.  With your legs straight, place your top foot on the ground in front of your bottom foot. Place your top hand on your bottom shoulder – be sure that your upper body does not twist or lean forward, brace abdomen, squeeze through your butt muscles, and lift hips up off the ground. Hold for 8-10 seconds, repeat 3 times. As the exercise becomes easier, increase the number of repetitions as opposed to the length of time.

3.  Stirring the Pot
This exercise starts on your hands and knees,  with your hands shoulder width apart directly under your shoulders, and knees hip width apart directly under your hips. Brace through your abdomen and squeeze your gluteals. Ensure you can maintain this while you take a breath in and out. Lift your right arm in front until it’s level with your shoulder, squeezing the muscles between your shoulder blades as you do so. At the same time, extend your left leg straight back until it is level with your hips, squeezing your gluteals, and keeping your hips square to the floor. Return to the starting position in a slow and controlled manner, and perform the same action with the left arm and right leg. That is one repetition. Perform 3 sets of 8-10 repetitions.

 

 

McGill also advises full-time desk jockey’s like me, who have a ‘flexion intolerant back’ to not focus on range of motion with back exercises.   His Big 3 have just as much to do with which exercises you shouldn’t do, than with what you should do.  McGill makes us keenly aware “that the spine discs only have so many numbers of bends before they damage”.  In a nutshell, he bluntly states that it’s better to do less of the thing that’s hurting you, flexion in many cases, rather than take medications to treat a strained back, or worse, protruding discs.

As always, check with your health care expert before attempting these exercises to prevent further injury…and take care.

 

Pain After Discectomy Surgery

The most commonly searched term on this blog is “pain after discectomy”.  So I’ve decided I would dedicate a post to this topic based on my personal experience and some recently published articles and videos.  This is by no means an exhaustive search for all that ails us after a discectomy, but I’ll do my best to provide relevant information that can answer the most common concerns regarding the types of pain some of us experience after undergoing this procedure, and possible treatments.

A discectomy is the surgical removal of the whole or part of an intervertebral disc that is often pressing on a nerve root or the spinal cord.     The procedure is most often performed by a qualified  orthopaedic surgeon or neurosurgeon.

Inflammation: 

One of the most common issues after surgery is inflammation especially at the incision point. Even minimally invasive, arthroscopic surgery will irritate some tissues and nerves and during this process inflammation can persist.  Most physicians will suggest over-the-counter medication to control and reduce inflammation.  I was sore for about a week and as you can see here, there was still a bit of puffiness around the 1″ incision.

Epidural Fibrosis (Scar Tissue): 

Sometimes after a discectomy, scar tissue forms near the nerve root and can cause extreme burning or nerve pain even if the surgery was successful in relieving the initial pain.  This type of postoperative pain is commonly called failed back surgery syndrome because you’ve swapped out one type of pain for another.

As Spine Health points out “Scar tissue formation is part of the normal healing process after a spine surgery. While scar tissue can be a cause of back pain or leg pain, in and of itself the scar tissue is rarely painful since the tissue contains no nerve endings. Scar tissue is generally thought to be the potential cause of the patient’s pain if it binds the lumbar nerve root with fibrous adhesions.”

Numbness:

After my last surgery (discectomy at L4/L5), I experienced some tingling and general numbness in the areas where my Sciatic pain was the most intense (bottom tibia/ankle and toes).  Months later a EMG revealed that I had permenent nerve damage caused not by the surgery but by the constant ‘zapping’ of the Sciatic nerve, pre-surgery.  Those who have had Sciatica know the feeling of this type of excruciating nerve pain which most likely deadened some areas on my leg and foot.  Here’s several accounts of other patients going through similar foot/leg numbness.

Aches / Spasms: 

Post L4/L5 discectomy, as the nerves began to heal I had a mild ache in my leg around the site of the sciatic nerve shocks.  I was told by my surgeon that this wasn’t uncommon and was caused by the nerve trying to repair itself.  Massage therapy can help with the aches as muscles can sometimes tighten from being inactive and without any type of stretching may lead to issues such as piroformis syndrome.

Re-herniation:

Current research suggest that there is a 2-18% chance of re-herniation dependent upon the size of disc defect as well as other factors such as disc height, pre-surgery.  It is most likely to occur in the first few weeks after surgery, and it’s strongly discouraged to lift anything heavier than 3-5 pounds during this period.  As this research concludes, there are no hard and set rules that make it more likely for re-herniation, however my personal suggestion would be to not strain yourself within the first 2-3 weeks and when ease into a work schedule rather than full-time duties with no easing in preparation.  Post surgery is also a good time to re-examine your sitting posture and to explore other options for working at a desk.

 As always, consult a doctor if you are experiencing discomfort and take care.

The Back Surgeries of Tiger Woods

In a previous post I listed the seven most famous professional athletes  to undergo back surgery, and as a followed up I’d like to shine a spotlight on the struggles of Tiger Woods, and his recovery from the crippling backpain that has sidelined his illustrious career.

Here’s a timeline of the spine procedures he has undergone:

April 2014 Back surgery No. 1: Woods undergoes his first back microdiscectomy to repair a pinched nerve that forces him to miss the 2014 Masters.

September 2015 — Back surgery No. 2: After playing in the Wyndham Championship, Woods undergoes his second microdiscectomy to remove a disc fragment that was pinching his nerve. “I’ve been told I can make a full recovery, and I have no doubt that I will.” Woods is forced to miss the Frys.com Open, Bridgestone America’s Golf Cup and his own Hero World Challenge.

October 2015 Back surgery No. 3: Woods has a follow up surgery to his September microdiscectomy. From all accounts the minor procedure is a success.

April 2017 —  Back surgery No. 4:  Woods withdraws from the Dubai Desert Classic in February and announces that he will undergo spinal fusion surgery in April leaving  doubts he will compete in the 2017 Masters. The surgery involved removing the damaged disc and re-elevating the collapsed disc space to normal levels. This allows the one vertebrae to heal to the other. The goal is to relieve the pressure on the nerve and to give the nerve the best chance of healing.

May 2017: Woods is arrested in Jupiter, Fla., on suspicion of driving under the influence. In a statement, Woods says alcohol was not involved and he had “an unexpected reaction to prescribed medications.”  It’s reported that Woods had 5 active drugs in his system upon his arrest.  “The report, prepared by the Palm Beach County Sheriff’s Office, says Woods, 41, had THC, the active ingredient for marijuana; as well as the painkillers Vicodin and Dilaudid; the anxiety and sleep drug Xanax; and the anti-insomnia drug Ambien in his system when he was arrested at 2 a.m. on May 29 about 15 miles from his home in Jupiter”.

July 2017: Woods tweets that he “recently completed an out of state private intensive program,” as he continues to seek professional help following his arrest for DUI on May 29. “I will continue to tackle this going forward with my doctors, family and friends,” the statement continues. “I am so very thankful for all the support I’ve received.”

Degenerative Disc Disease

The stiff, aching and often burning sensation in my lower spine started in my late twenties and ten years later, when I had my first MRI, it was clear that Degenerative Disc Disease was one of the root causes of my lower back pain.

It’s said that as many as 80% of healthy adults experience some sort of back pain between the ages of 30 and 50, however Degenerative Disc, the loss of fluid in the discs between each vertebrae are padding for the spinal column, and without them every step can send shockwaves through the spine, making healthy living a real challenge. Age, poor posture, and injury can weaken discs between vertebrae, causing tearing along the disc walls.

To treat DDD, many medical specialists first recommend conservative, non-surgical treatments such as physical therapy or chiropractic treatment in an effort to stretch the space between discs and relieve the pressure on surrounding nerves.  Manual manipulations on a decompression table can lift and separate discs to ease the strain on the lower back and some doctors may also recommend non steroidal anti-inflammatory drugs to reduce the burning sensation that often builds up when there’s no separation between vertebrae caused by collapsed discs.

Surgical options to reduce the pain of DDD include:

Discectomy:  the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves.

Laminectomy: surgery that creates space by removing the lamina — the back part of the vertebra that covers your spinal canal. Also known as decompression surgery, laminectomy enlarges your spinal canal to relieve pressure on the spinal cord or nerves.

Spinal fusion: a neurosurgical or orthopedic surgical technique that joins two or more vertebrae. This procedure can be performed at any level in the spine (cervical, thoracic, or lumbar) and prevents any movement between the fused vertebrae.

Lumbar Total Disc ReplacementWith artificial disc replacement, pain relief is brought about by removal of the painful disc and motion is maintained with the use of a prosthetic implant made of metal (with or without a plastic bearing surface). This is more similar in theory to the artificial hip, knee, and shoulder joints that orthopedic surgeons have been using for more that 35 years to maintain motion and relieve the pain of arthritic extremity joints. However, there is a significant difference in that only one of the three joints that are present at each vertebral level is being replaced, whereas a hip or knee joint the total joint is replaced.

In recent months, restorative types of treatment have emerged to repair damaged vertebrae discs.

Mesoblast Cell TherapyAll therapies for progressive, severe and debilitating pain due to degenerating intervertebral discs treat the symptoms of the disease, but are not disease-modifying and thus do not address the underlying cause of the disease.  This type of treatment involves a single intra-discal injection of 6 million MPCs resulted in meaningful improvements in both pain and function that were durable for at least 36 month.  For more information regarding this new therapy, please check out this link.

Platelet-Rich Plasma TherapyA clinical study of 49 patients who underwent intradiscal platelet-rich plasma (PRP) injections for low back pain found significant improvements in pain and function through two years of follow-up. Dr. Gregory Lutz, Founder and Medical Director of the Regenerative SportsCare Institute, and Physiatrist-in-Chief Emeritus, Hospital for Special Surgery, presented the two-year results at the Interventional Orthopedics Foundation’s Annual Conference in Broomfield, Colorado last month.

For simple, home-use products, Dr. Dan Perez outlines a few options and the advantages / disadvantages of each:

 

Here’s a video describing What Degenerative Disc Disease Is, Causes, Symptoms, Treatments

Lumbar Microdiscectomy: What to Expect at Home

From the Myhealth.alberta.ca site:

Your Recovery

Microdiscectomy is surgery to remove part or all of a bulging (herniated) disc in the spine. A bulging disc may press on the spinal cord or spinal nerves and cause leg pain and numbness. Your doctor made a 2.5 to 5 centimetre cut (incision) in the skin over the spine. He or she inserted a special microscope (scope) to see the area and then used surgical tools through the incision to do the surgery.

You can expect your back to feel stiff or sore after surgery. This should improve in the weeks after surgery. You may have relief from your symptoms right away, or you may get better over days or weeks. In the weeks after your surgery, it may be hard to sit or stand in one position for very long and you may need pain medicine. It may take up to 8 weeks to get back to doing your usual activities.

Your doctor may advise you to work with a physiotherapist to strengthen the muscles around your spine and trunk. You will need to learn how to lift, twist, and bend so you do not put too much strain on your back.

This care sheet gives you a general idea about how long it will take for you to recover. But each person recovers at a different pace. Follow the steps below to get better as quickly as possible.

How can you care for yourself at home?

Activity

  • Rest when you feel tired. Getting enough sleep will help you recover.
  • Try to walk each day. Start by walking a little more than you did the day before. Bit by bit, increase the amount you walk. Walking boosts blood flow and helps prevent pneumonia and constipation.
  • Avoid lifting anything that would make you strain. This may include heavy grocery bags and milk containers, a heavy briefcase or backpack, cat litter or dog food bags, a vacuum cleaner, or a child.
  • Avoid strenuous activities, such as bicycle riding, jogging, weight lifting, or aerobic exercise, until your doctor says it is okay.
  • Ask your doctor when you can drive again.
  • Avoid riding in a car for more than 30 minutes at a time for 2 to 4 weeks after surgery. If you must ride in a car for a longer distance, stop often to walk and stretch your legs.
  • Try to change your position about every 30 minutes while you sit or stand. This will help decrease your back pain while you heal.
  • Your time off from work depends on how quickly you feel better and on the type of work you do. If you work in an office, you likely can go back to work sooner than if you have a job where you are very active. Talk with your doctor about your work needs.
  • You may have sex as soon as you feel able, but avoid positions that put stress on your back or cause pain.

Diet

  • You can eat your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
  • Drink plenty of fluids (unless your doctor tells you not to).
  • You may notice that your bowel movements are not regular right after your surgery. This is common. Try to avoid constipation and straining with bowel movements. You may want to take a fibre supplement every day. If you have not had a bowel movement after a couple of days, ask your doctor about taking a mild laxative.

Medicines

  • Your doctor will tell you if and when you can restart your medicines. He or she will also give you instructions about taking any new medicines.
  • If you take blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, be sure to talk to your doctor. He or she will tell you if and when to start taking those medicines again. Make sure that you understand exactly what your doctor wants you to do.
  • Be safe with medicines. Take pain medicines exactly as directed.
    • If the doctor gave you a prescription medicine for pain, take it as prescribed.
    • If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
  • If you think your pain medicine is making you sick to your stomach:
    • Take your medicine after meals (unless your doctor has told you not to).
    • Ask your doctor for a different pain medicine.
  • If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.

Incision care

  • If you have strips of tape on the cut (incision) the doctor made, leave the tape on for a week or until it falls off.
  • Wash the area daily with warm, soapy water, and pat it dry. Don’t use hydrogen peroxide or alcohol, which can slow healing. You may cover the area with a gauze bandage if it weeps or rubs against clothing. Change the bandage every day.
  • Keep the area clean and dry.

Exercise

  • Do back exercises as instructed by your doctor.
  • Your doctor may recommend that you work with a physiotherapist to improve the strength and flexibility of your back.

Other instructions

  • To reduce stiffness and help sore muscles, use a warm water bottle, a heating pad set on low, or a warm cloth on your back. Do not put heat right over the incision. Do not go to sleep with a heating pad on your skin.

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse call line if you are having problems. It’s also a good idea to know your test results and keep a list of the medicines you take.

When should you call for help?

Call 911 anytime you think you may need emergency care. For example, call if:

  • You are unable to move a leg at all.
  • You passed out (lost consciousness).
  • You have sudden chest pain and shortness of breath, or you cough up blood.

Call your doctor or nurse call line now or seek immediate medical care if:

  • You have pain that does not get better after you take pain medicine.
  • You have new or worse symptoms in your legs or buttocks. Symptoms may include:
    • Numbness or tingling.
    • Weakness.
    • Pain.
  • You lose bladder or bowel control.
  • You have loose stitches, or your incision comes open.
  • You have signs of infection, such as:
    • Increased pain, swelling, warmth, or redness.
    • Red streaks leading from the incision.
    • Pus draining from the incision.
    • Swollen lymph nodes in your neck, armpits or groin.
    • A fever.
  • You have blood or fluid draining from the incision.

Watch closely for changes in your health, and be sure to contact your doctor or nurse call line if:

  • You do not have a bowel movement after taking a laxative.
  • You are not getting better as expected.

 

Discectomy Cost: The Price of Pain Relief

Can you really put a price on a healthy back ?  You certainly can.  And if you’re suffering from a herniated disc it’ll cost you anywhere between $20k – $80k depending on your surgical team and the type of surgery you choose – minimally invasive costing less.  For patients that have a good insurance policy, the deductible is pegged at somewhere between 10 to 40 percent of the cost of the procedure.

Some forum users at Spine-Health and eHealth provide a few facts and figures into the cost of their surgery as well as cheaper options such as signing up for clinical trials.  “Average national costs were about $14,000 for a single-level ACDF procedure and $26,000 for a single-level PLF. (These total figures reflected combined professional and facility costs.) Average cost for KA was about $13,000, increasing to $22,000 for TKA in patients with accompanying other major medical conditions.”

Hub Pages provides an example of the costs associated with Microdiscectomy.

Example: Summary of Microdiscectomy Cost

Description
Amount (USD)
Hospital Services:
Anesthesia
1128.00
Medical Supplies
1969.00
Pharmacy
978.50
Radiology
646.00
Recovery Room
2466.00
Surgery
4586
Surgeon’s Fee:
6329.00
Anesthesiologist’s Fee:
1890.00
TOTAL CHARGES:
$19,992.25
Source: Fees for microdiscectomy performed in a Chicago-area hospital; Feb. 2012
From this list at Pricing Healthcare, you can see that prices for discectomies vary from state to state in the US, ranging between $8000 – $11000. However, make sure you read the ‘Notes’ at the bottom of each list to understand exactly what’s covered.
More recently, this study through the University of Utah shows the varying costs of spinal fusion, anterior cervical discectomy/fusion and posterior lumbar fusion.  And Becker’s Spine Health breaks down the cost between a discectomy and laminectomy.

Fortunately, for those of us living in Canada, microdiscectomy cost is covered by the government.  Universal health is definitely one of the major benefits of living North of the 49th parallel.  Perhaps another option for those Americans looking to get a microsurgery done sooner rather than later.  Here’s Warner Nickerson’s story of getting the procedure done in Croatia.  And if you live in France, this study states a discectomy costs around $650 US (approx. 4000 Francs).

Back to Work: How Soon Is Too Soon?

Three weeks after my first back surgery in 2010, I had convinced myself that everything had gone smoothly and that I was ready to return to work.  After all, the swelling and inflammation had gone done considerably and I was starting to feel like my old self.

As I sat back in my once comfy office seat, it didn’t take long to realize that the old habits that had twisted my back into a knot would return to do the same if I didn’t make some adjustments.  The first adjustment would be mental.  I had to tell myself that I wasn’t rehabilitated yet and that office work could wait.  Luckily, I had an employer that was very supportive and allowed for flextime so that I could work PT in the office and the rest of the time at home.  This gave me an extra month to let the scar tissue and alignment issues settle down.

So when is it too soon to begin work again?  A recent study presented at American Association of Neurological Surgeons Annual Meeting, finds that on average people who were working before a single layer lumbar discectomy were able to return to work in 67 days post surgery.

Though my personal opinion is that it’s different for everybody and that you’ll need to really stay in tune with your body.  I know that doesn’t help much but setting an unrealistic recovery schedule might just drag you right back to the operating table.  Alberta Health Services has some common sense tips on what to do when you do decide to get back to the 9-5.  The most important in my opinion would be to not sit for too long.  Stand up and do some light stretching or if possible, go for frequent short walks to keep blood flowing to the back.  These little preventative measures have made a huge difference in the productivity and quality of the office life.

 

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Q & A With A Surgeon

Here’s an excellent question and answer interview with Dr. Michael Barnes, an Orthopaedic surgeon practicing in New Zealand.  He answers several questions post lumbar micro-discectomy.

Here are the Key Points:

Key Points

  • A disc protrusion (disc herniation) occurs when a piece of the intervertebral disc (the soft part between the vertebrae) separates or partially separates and compresses a nerve in the lower spine.
  • Disc protrusion with pressure on a nerve causes sciatica which is pain down the leg in the line of the sciatic nerve and may also cause weakness or numbness.
  • Sciatica often gets better within days or weeks without treatment but sometimes
    persists for months and sometimes never gets better without surgical treatment.
  • Surgery is performed under general anaesthetic and usually takes 30 to 60 minutes.
  • Surgery involves extraction of the disc fragment from under the nerve root through a 3cm to 4cm incision (longer in large patients).
  • Some patients go home the day after surgery, some on the second day.
  • Return to work is variable and may occur in as little as one to two weeks for
    sedentary workers who can get up and walk periodically or may take up to two to
    three months for heavy manual workers.
  • Complications or post operative problems are rare with the exception of recurrent
    disc protrusion which occurs in 2% to 3% of patients in the first year after surgery and 10% at ten years from surgery.

And the full length article can be found here

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