Dr. Eric Chehab: Welcome to IBJI OrthoInform, where we talk all things orthopedic to help you move better, live better. I’m your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day.
Today, it’s my pleasure to welcome Dr. Cary Templin, who will be speaking about spinal fusion surgery. As a brief introduction, Dr. Templin graduated from the University of Cincinnati Medical College, where he received his medical degree in 2001. He came to Chicago for his residency at Northwestern and afterward completed his spine fellowship at the University of California, San Diego, one of the country’s most prestigious and innovative spine fellowship training programs. Dr. Templin is an expert in minimally invasive spine surgical procedures. His practice specializes in spinal decompression and fusion surgery, microsurgery and motion-preserving surgeries, including artificial disc replacement.
In addition to his clinical practice, he’s the co-author of several book chapters on spine surgery. He has published numerous peer-reviewed articles in spine journals. He’s a dedicated member of the American Academy of Orthopedic Surgeons, the North American Spine Society, the Society for Minimally Invasive Spine Surgery and the American Orthopedic Association’s Emerging Leaders program.
Cary has helped thousands of patients recover from debilitating spine and neck conditions. Cary, welcome to OrthoInform and thank you for being here today.
Dr. Cary Templin: Thanks Eric. Thanks for hosting me here today.
Dr. Eric Chehab: Let’s get right into it. Spinal fusion. First of all, what is a spinal fusion?
Dr. Cary Templin: Spinal fusion is simply a procedure that, in the end of it, makes two bones grow together and we do so by placing bone graft, sometimes screws or instrumentation to hold the bones together. And then sometimes spacers that we place the bone graft into that do more than just hold bone graft. They can actually separate the bones and make room for nerves. But at the end of the day, a spine fusion procedure is simply making two bones grow together and you can do this for two bones. You can do it for 20 bones. It depends on the reason you’re doing it.
Dr. Eric Chehab: So what are some of the reasons that people need a spine fusion?
Dr. Cary Templin: We as spine surgeons do two procedures. That’s what I commonly tell people. We do what are called decompressions, where we make room for nerves that may be causing pain to radiate into someone’s arms or legs called radiculopathy.
Sometimes we have to decompress a really big nerve called the spinal cord and in the process of doing so, we sometimes develop some what we call iatrogenic instability, where we have to remove the stabilizing parts of the spine. And so we’ll do a fusion procedure, so it doesn’t become more painful.
Otherwise there are certain indications such as scoliosis or deformity where the patient’s spine is curved, and we need to realign it. Not only when you look at it and it looks like an ‘S’ from the front, but from the side, one of the things that a lot of research has been dedicated to recently is to improve balance to keep people standing upright instead of leaning forward. Otherwise a very common indication for a spinal surgery. A fusion is a diagnosis called spondylolisthesis where bones slide out of alignment, which then allows nerves to get pinched and causes that pain radiating into the legs and otherwise.
Dr. Eric Chehab: So the big indications, it sounds like, are compression of nerves, including the spinal cord itself. Deformity where the spine is crooked and causing people to be out of balance and then instability of the bones in the spine, which can cause pain in and of itself, and then pinch the nerves when the bones are moving around when they shouldn’t be.
Dr. Cary Templin: Absolutely. And then another indication would be degenerative disc disease, but that’s sort of where spine fusion surgery got a bad name. Quite some time ago, it was a procedure that was done for people who had even mild degeneration of this. And they found that people didn’t do as well with that diagnosis.
Now, there are still people that are fused for degeneration of the disc, but in those patients, we need to see some other criteria to indicate that a fusion will help them.
Dr. Eric Chehab: Got it. And what are some of those criteria, by the way?
Dr. Cary Templin: So we’re looking for inflammation of the bony end plates, when we get an MRI, which gives us a really nice picture of the bones and nerves, we can see that the impact of one bone on another one, the disc that’s between them wears out is causing almost what looks like a fracture or just inflammation within the bone.
And that edema in the bone, sort of pushes us in a direction that a fusion might help that patient. But back in the day, they were doing what we called black disc disease in the late nineties and fusions were rampant. And I think that’s what really started to give a spine fusion procedure a bad name.
Dr. Eric Chehab: So spine fusion remains a scary concept for many, but you’ve simplified it beautifully. It’s just taking two bones that don’t move too much to begin with and making them one, correct? Yes. And you’re doing it for reasons that are very important when, if a nerve is being compressed or if these segments of the bone are getting more crooked or people are getting out of balance or if, God forbid, those segments are moving more than they should and causing a lot of pain and a lot of nerve compression, those seem like great reasons to make those bones, two bones into one or three bones in a two or one, as you’re saying. So, let’s talk about two areas of the spine that seemed to have the most trouble with those three conditions of nerve compression of deformity and of instability.
And it’s generally in the neck and the lumbar spine, is that correct? Correct. The thoracic spine is much more stable because of the rib cage and the bones that help surround it. Is that correct? Yes, that’s correct. So when we talk about spine fusion, we’re usually talking around the neck and in the lower back.
That’s correct. Okay. So let’s take a look at the typical patient who comes in with, let’s say neck problems. What are some of the symptoms they might have?
Dr. Cary Templin: Sure. People that come in with neck problems, they’re going to complain of predominantly some aspect of neck pain. They will complain of, if it’s a nerve that’s pinched, they will complain of pain that radiates down the arm, potentially some tingling or numbness.
And in other people who have spinal cord compression, they will complain of more of a diffuse numbness and tingling, maybe some lack of coordination, and even at times, difficulty ambulating to the point that they need a walker or cane. Those patients may be presenting with evidence of spinal cord compression.
Dr. Eric Chehab: So, and that’s a big deal. Spinal cord compression. That’s no joke.
Dr. Cary Templin: Yes. And when we do surgery in that regard, our goal mainly is to stabilize the spine and decompress the cord so that we don’t have any progression of that condition because once it gets too far along, it doesn’t improve very much.
Dr. Eric Chehab: And then let’s take a look at the lower back, the lumbar spine. What does that patient, what symptoms are they going to have?
Dr. Cary Templin: So those patients will come in with complaints of pain radiating into the legs. A lot of times, some back pain as well. And then it comes down to what your workup shows. We have talked about spine fusion. If a patient comes in with a herniated disc, for instance, with pain shooting down their leg, they don’t need a spine fusion.
That person will benefit from a decompressive surgery alone, which doesn’t involve screws and rods and bone graft. However, if we do see those other indications, such as instability or deformity that’s leading to the problem, or if we’re going to need to resect a lot of bone or ligament to decompress those nerves, we add a fusion to the procedure. That said, patients commonly will come in, they can have pain radiating down the leg. They can have weakness or numbness. Those are less common, especially the weakness. And then when someone’s got weakness, we sort of act on it more quickly. When it’s a significant portion of pain, we try to treat things conservatively. We do physical therapy. We send them for potentially epidural injections that may help, but when those things don’t help, then it’s time to consider surgery.
Dr. Eric Chehab: Got it. So a patient comes to you with numbness in their hands, pain in their hands, from the neck problem or numbness or pain in their leg from the back problem, what are some of the studies that you get in order to evaluate this further?
Dr. Cary Templin: We start typically with an upright x-ray because that’s when most people have their problems, when they’re up moving. We also take a flexion extension x-ray from the side to see if the bones are sliding out of alignment.
Dr. Eric Chehab: And what do you do with that flexion extension x-ray?
Dr. Cary Templin: So, what we do is the patient will, we’ll take a picture from the side. If it’s the neck, for instance, the patient will bend their head forward and back. And we’re looking to see if the bones are sliding, which would be an indication of instability there, which would indicate potentially where the problem is.
Dr. Eric Chehab: So you could see that on an x-ray? Absolutely. And the same thing with the back? Yes. With the lower back? Yes. Okay. And then beyond x-ray?
Dr. Cary Templin: Beyond x-ray, if there is evidence of nerve compression, such as the patient complaining of arm pain, and if they have any neurologic deficits, they may be sent after an initial course of maybe some anti-inflammatory medication or some physical therapy, we’ll send them for an MRI scan to further define things.
But an x-ray will show us bones really well. It can show us the height of the disc space, but it doesn’t show us the nerves. It doesn’t show us the spinal cord and that’s where an MRI comes in and really gives us that information as to what exactly may be causing the patient’s problem. And secondly, how bad it is.
Dr. Eric Chehab: Now with an MRI, there’s a little bit of background noise with MRIs. Well, I see it in the shoulder that there’s just sort of age-related changes that may not be contributing to the problem. What’s the incidence of having, let’s say, a herniated disc, when you take an MRI of the lower back, that may not have anything to do with a patient.
Dr. Cary Templin: Absolutely. There’s been a, a number of studies that have shown in patients between the age of 40 and 60, for instance, if they have an MRI done of their neck or back, they are going to have bulging discs 40 to 60% of the time. And these were done in asymptomatic patients.
Dr. Eric Chehab: So they have no symptoms whatsoever, yet they have a bulging disc. And so we just accept that as part of life. Absolutely. So then how do you piece together the bulging disc that matters?
Dr. Cary Templin: Basically what we do is we take a history from the patient. We want to know where their pain is going, what causes it to go there, what other symptoms they may have. Does their arm feel weak? Do they feel numb? And then you look at that history, you examine the patient. See if you can elicit some of the provocative signs that may point to a problem of a pinched nerve or something, see if they’re weak, check their reflexes.
And then, beyond that, our imaging studies come into play to say, okay, does the history, the physical and the diagnostic imaging studies, do they all put together a story which would explain why this patient is experiencing the problem they’re experiencing?
Dr. Eric Chehab: So let’s move forward from that point of the diagnosis and get into some of the treatment. Can you talk about some of the non-operative treatments that you have at your disposal for patients who are suffering from neurologic compression from instability of the spine from even the deformities? What are some of the non-operative treatments that you can use?
Dr. Cary Templin: In patients that are complaining of predominantly pain, as we mentioned, these patients will be given a course of anti-inflammatory medication, if they can tolerate it. Sometimes even an oral steroid, which will decrease the inflammation. What we know is that the pressure on the nerves actually causes inflammation of the nerve. So even if you’re not getting rid of that pressure, if you can diminish that inflammation, you can reduce the symptoms. Secondly, beyond that, the next option would be physical therapy.
If patients can work on stabilizing their spine with the muscles that control the spine, this can help to eliminate symptoms. Postural and positional training, that can help to reduce symptoms. Beyond physical therapy, if we do see that there is evidence of nerve compression, epidural injections, which means that we take a needle and go where the nerve is and put steroid medication to directly diminish the inflammation. What I tell patients is it’s like taking the ibuprofen that they’re taking, that goes all over their body. Some of it goes to their shoulders. Some of it goes to their knee. In this case, you’re taking the steroid and putting it right where it needs to work.
Dr. Eric Chehab: So someone who is having these symptoms and elects to try non-operative treatment, what’s a duration of time that they can do that safely?
Dr. Cary Templin: As long as they don’t have significant neurologic symptoms, such as weakness, they can do that as long as they would like.
Dr. Eric Chehab: So is weakness the big trigger, is that the big sign that you’re looking for, that they’re not developing muscle weakness as a result of their nerve compression?
Dr. Cary Templin: For me, typically in what I tell patients is as long as they don’t have that, and a lot of people are afraid of surgery and I tell them they can explore other opportunities, but if they start to develop weakness and you don’t address it in a timely fashion, two to three months, there’s a chance that that could become permanent. And that’s with sort of mild to moderate weakness. If they have significant weakness right off the bat, then there’s usually a surgical recommendation right away.
Dr. Eric Chehab: Let’s talk about the surgical treatment and let’s start with the neck, the cervical spine. What are some of the options that patients have for when they’re having either severe weakness that presents right away or longstanding chronic weakness, or just terrible, terrible pain that’s intractable and hasn’t responded to any of the non-operative modalities. What are the surgical treatment options available for the neck?
Dr. Cary Templin: So when they present with radiculopathy or myelopathy, which means spinal cord compression. The most common treatment that we will offer, assuming it’s a couple levels, maybe one level, two level, three level, even four, is what’s called an anterior cervical discectomy and fusion (ACDF), which means from the front approaching the neck, taking the disc out and making room for the spinal cord and nerves. And then we simply place a spacer, either a piece of bone or a piece of plastic with bone in it, and then a small plate and screws that holds everything in place. The advance of having instrumentation in the front of the neck has saved people from having to be put into a halo, which is that device that looks like one of those dog collars that people couldn’t move their necks. Right. And makes it a much more stable procedure. And, ACDF is an excellent procedure. Trauma to the tissues is minimal and people make a really quick recovery from that.
Dr. Eric Chehab: Is that something that could be done on an outpatient basis?
Dr. Cary Templin: Absolutely. For one to two to three levels. Yes, typically one to two levels can be done as an outpatient.
Dr. Eric Chehab: So I love ranking surgeries. Like what’s the number one surgery and, you know, total hip replacement and cardiac bypass. And ACDF seem to be jockeying for the number one position all the time, because it’s a very durable procedure and it’s an unbelievably effective procedure.
Dr. Cary Templin: Yes. If you look at outcome rates of ACDF procedures, uh, you’re looking in the neighborhood of 90% or so. And so those patients do really well and because it’s a less traumatic approach, people have a really good outcome.
Dr. Eric Chehab: It’s an easier recovery because of that. Yes. And then let’s go to the lumbar spine to the lower back. What pushes you to surgery and what are the surgical treatment options for that?
Dr. Cary Templin: Indications for surgery in the lumbar spine would be, especially for a spinal fusion would be instability or deformity leading to nerve root compression that requires decompression and stabilization, after usually a course of anywhere from six weeks to six months of non-operative treatment, including injections therapy and otherwise. Now when you have a patient, let’s just say for instance, an L-4/5, which is the second level up in the spine, and they have a spondylolisthesis there, which means that the top bone slides forward.
So if you picture two rings stacked on top of one another and you move one of them forward, it’s going to close down the space between those two rings and that’s what’s happening to the nerves. So in that case, that patient would be a candidate for a one-level decompression and fusion. That could be done either in a traditional open way where a three- or four-inch incision is made on their back and the muscles are removed from the bone.
The bone is removed that is pushing on the nerves and then screws are placed in and a bone graft is placed. Over the last, probably 15 years, there has been a significant move towards minimally invasive procedures, where using tubes, and approaching the spine either from, just off to the side of the back instead of a big midline incision, or even straight from the side or from the front, a spacer can be placed in between the bones and then screws can be placed either open or percutaneously that will allow us to completely realign the spine, taking the pressure off the nerves and stabilizing it. And what we found with minimally invasive procedures such as that is that there is a faster return to function. If you look at overall outcome scores, either surgery, the traditional or the minimally invasive are going to do well.
But we look for less blood loss with minimally invasive [surgery], shorter hospital stays and a faster return to function. Although we do still have to protect the patient because we need to let the fusion heal, so they can’t get back to activity and sometimes even have to slow these patients down some.
Dr. Eric Chehab: So the idea of a slipped disc that usually doesn’t require a spinal fusion, correct?
Dr. Cary Templin: Correct. You just take that out. Herniated disc, you make a little window into the spinal canal, move the nerve over and take the disc out. Those people are up moving in. You know, they’re walking right away. They’re moving in and about four to six weeks, they’re back to pretty normal activities.
Dr. Eric Chehab: And then taking it a step further. The spine fusion would be recommended for those patients with the instability, with the nerve compression that isn’t resolved by simply removing a disc, or if in order to decompress the nerve, you have to remove the stabilizing structures, that that would be a reason to make two bones in one.
Absolutely. Okay. So let’s take that patient, again going back to the neck. What are they experiencing over the first week? Over the first month? Over the first three months, let’s say with a simple one level fusion, the most common procedure that would be done in the neck.
Dr. Cary Templin: The first week, what you’re going to tell patients is expect them to have some, uh, it’s almost like a sore throat, like strep throat. That’s the pain of the surgery. It’s not a super painful surgery. Tell them to expect a little problem with swallowing, just because you have to move their esophagus over.
And so it gets a little irritated. But this patient is up immediately. Most of the patients that stay overnight, they’re ready to go home by nine in the morning the next day, otherwise do them as an outpatient and they’re moving. And a lot of times people are really afraid to have surgery.
It makes sense. Anterior cervical fusion patients typically can’t believe how easy the procedure was and they’re up moving right away. So over the first week they find they’re, you know, they’re up going to their kid’s baseball games, that kind of thing.
Dr. Eric Chehab: And when do their symptoms start to resolve?
Dr. Cary Templin: The arm pain and the neurologic symptoms will start to resolve immediately, that once you remove that pressure from the nerve, may have a little residual numbness just from what I call the stepping-on-the-toe phenomenon. Basically, if I stepped on your toe for six weeks and I took my foot off, you’d feel really good, but you might have some residual inflammation. You won’t find that in a textbook, but that’s the way I explain it to patients. And then over time, that numbness can improve.
Dr. Eric Chehab: And then what about for the lower back what’s the first week, the first month look like for that patient?
Dr. Cary Templin: So the lower back, let’s say a one-level fusion for the lower back. There’s sort of been a shift with that. Even some of those procedures are being done as an outpatient, with the goal of early mobilization. So a patient that stays in the hospital, they’re going to be seen the same day by physical therapy, work on getting them up, getting them moving, because what we want is we want to get people moving out of the hospital. It helps to diminish the use of narcotic pain medicine, and otherwise gets their bowels moving. So we want people to get up and move as quickly as possible.
Dr. Eric Chehab: Okay. Now what about pain management around the time of surgery? I think people have a misconception in my opinion, that the surgeries are terribly, terribly painful when, in fact, most of the surgeries are pain-relieving, correct?
Dr. Cary Templin: Yes. I mean, when you do the surgery, you have this horrible pain shooting down your leg. Um, it’s going into surgery. Yes. And I tell people it’s so bad that people let me cut them open and it really is because I’ve lived through it and we can get back to that later. But at the end of the day, what happens when you do the surgery is, when you take the pressure off the nerves, the leg pain, the neurologic symptoms go away and the patient is sore and they’re back. And what I tell my patients is you’re going to need some pain medicine around the time of surgery. And what we try to do is minimize that, but I also tell patients that you need to use the pain medicine, so you can be mobile, so you can be up and about and get back to your normal activities.
I frequently get the question of, ‘well, I’m afraid to become addicted.’ And what I tell patients is if you don’t have pain and you don’t take the medication, then you won’t be addicted. If you have pain, it’s okay to take some as prescribed.
Dr. Eric Chehab: Now, what are some of the pitfalls, let’s say with a cervical neck surgery, what are some of the more common complications that can occur?
Dr. Cary Templin: As we talked about, people can have some problems with swallowing. It’s a really straightforward procedure. I mean, there are catastrophic things that can, and probably have gone wrong. Everybody’s question when we go through one of these surgeries is, ‘Can I be paralyzed?’
And the answer is it’s theoretically possible. In my practice, I do the work on the neck, under a microscope. So we use little, two-millimeter instruments to pick the stuff off the spinal canal and off the spinal cord. I tell the patients, the likelihood is, is one in a hundred thousand, one in a million. I mean, I can’t even give them a number cause it’s so infrequent.
Dr. Eric Chehab: No, I, I just used this analogy. They’re more likely to have a paralysis probably driving to the [surgery] center and getting in a car accident than anything that would happen in the surgery.
Dr. Cary Templin: I think that’s correct. I mean, there are some cases in the neck where there’s severe spinal cord compression and you know going in that this is going to be a problem. And those patients are cautioned that that is a more significant risk. There’s something called reperfusion injury that can happen where, when the blood flow to the cord opens up, it can cause those problems. But that’s extremely unlikely.
Dr. Eric Chehab: And their option of doing nothing isn’t very good either. It’s terrible in that situation when they’re in that severe condition.
Dr. Cary Templin: That’s a great point. And that’s what I tell the patient. You’re in a very controlled environment where we’re doing this. Whereas if you let it go, the inevitability is that at some point, you probably will get to the point that you’re not walking here.
Dr. Eric Chehab: And then for the lumbar surgery, for the lower back surgery. What are some of the common pitfalls that can occur there?
Dr. Cary Templin: Every surgery has complications and nobody wants to have them. At the end of the day, what we do is we look at what are the common issues that could occur with any procedure that we’re doing.
And we prepare and prepare and prepare with plan A, B and C, in regards to how to avoid those things. Sometimes during the decompressive procedure, there’s a thing called a dural tear, in which a person can develop a spine fluid leak, in which case we have to know what the risk of that is, what the likelihood that’s going to happen and be ready for it if it’s going to. A person that’s having a revision surgery, for instance, has a three to five times higher risk of that problem.
Dr. Eric Chehab: Is that because of all the scar tissue that’s formed?
Dr. Cary Templin: Exactly. And so you’re trying to decompress the nerves, but the lining around the nerves which contains the spinal fluid, is like a tissue paper. And so you have to stay out of that, but understanding that that may happen. You explain that to the patient. I tell them exactly what the management will be, uh, so that if it does happen and you say, well, you had this issue, they understand where you’re coming from and that it was a risk. Because I think people, when they’re sort of blindsided by a complication, they don’t understand.
So other things, I think really when you look at the failure of lumbar spine surgery or cervical spine surgery, it’s either the wrong diagnosis potentially. You’re operating on someone that you think has this problem and they may have another problem. And that’s where our diagnostics really come in.
And then being aware of the patient. Smoking in a fusion procedure is an absolute no-no. A five times higher rate of the bones failing to grow together in patients that smoke. Patients need to be compliant with activity and bracing and otherwise after surgery so that we don’t have problems.
Another issue is preoperative pain medicine use. We need to get that down as much as possible because, in patients who are on heavy doses of pain medicine before, it’s impossible to manage their pain post-operatively, so they don’t move as much as they should and otherwise. And then, for instance, as a surgeon, it’s knowing my limitations, I don’t do major big, huge back surgeries.
It’s just not what I do, Dr. Mardjetko here at IBJI, that’s what he does. And if someone had something like that, I would send it to Dr. Mardjetko because that’s what he does. And he would have a much higher chance of not having a problem with that patient than I would.
Dr. Eric Chehab: Now in terms of after surgery for the cervical spine, again, dividing them, how important is physical therapy for that patient with the neck surgery?
Dr. Cary Templin: Physical therapy is very interesting question. In the neck, probably less than 50% of my patients will need it, but it really depends on their preoperative condition. If they’re weak, before surgery, then you may need to push that a little bit more after to get them moving, to get their strength built back up.
That kind of thing. A lot of them, if they have spinal cord compression, they may need gait training, that kind of thing. In the low back, it’s really dependent on how you do the procedure. If you’re doing a minimally invasive one-level surgery, probably less than 50% of people need to have anything done for physical therapy.
However, if you’re having a three-level fusion and you’ve been minimally walking because of your symptoms for the last six months, those people are going to need some more therapy. Exactly.
Dr. Eric Chehab: Okay. Now, long-term, let’s say five, 10 years down the road, if you’ve had a cervical fusion, are there any repercussions of the procedure that you had five to 10 years ago.
Dr. Cary Templin: There is a phenomenon called adjacent segment degeneration. What that means is that you fuse one or two levels and the levels above, because that one level doesn’t move anymore, it takes a little bit more strain.
So there are documented rates of those levels going bad. But the question is, is it the actual fusion or is it just the natural progression of that disc going bad over time? If you did, or didn’t do the fusion in the first place, um, what we know is that at about a ten-year period, there’s a 20 to 30% chance of having problems at an adjacent disc, either in the neck or the low back.
Dr. Eric Chehab: This is what people really should know, is that these types of fusion procedures, aren’t the scary, the world’s coming to an end type of procedure. In fact, they’re very, very useful for many, many patients suffering from terrible pain, even their arms from their neck or down their legs from their back. So, why do you think the stigma developed around spinal fusion in general?
Dr. Cary Templin: There is absolutely a stigma. If I mentioned the word fusion to a lot of patients, you would think I was talking about the devil. They immediately get turned. You can see their face; they get turned off.
I’ve had several occasions where I’ve recommended for a specific reason, a fusion on a patient. They go for a second opinion. They’re not given a fusion. They’re given a decompressive procedure alone. They’ve gotten worse and now they come back and see me. Right. And they say, ‘oh, I wish I would have done that.’
That said, people should go get a second opinion if they’re worried about it. I always encourage them to at least come back and talk to me. But the stigma, I think it comes from everybody knows someone that had a fusion and says, ‘oh, they did horribly.’ And at the end of the day, the success of a fusion procedure depends on why you’re doing it as we’ve discussed the solid indications, who you’re doing it on and how you do it.
If you do a minimally invasive procedure, if you do a traditional open procedure, as long as it’s for the correct indication and done with the correct technique, the patient’s going to do well.
Dr. Eric Chehab: And on the correct patient, the non-smoker, someone who was going to have a higher likelihood of success.
Dr. Cary Templin: Absolutely. I mean, I think that taking those things into consideration, there’s been some famous people recently who have had spinal fusion procedures, we’ve seen Tiger Woods have spinal fusion procedure and go back and win the Masters. You have Peyton Manning who had a neck fusion procedure and he went on to win the Super Bowl and the MVP.
So those have really helped me to talk to patients about these issues. Um, too, what about your own. Yes. I, in October of 2019 had a spinal fusion of L-5/S-1, which was the lowest segment of my spine. Basically what had happened was I started to develop pain from my back shooting into my right leg.
And so I would be operating on people and I’d have to bend over for 30 seconds and stand back up and it took me, which is ridiculous as a spine surgeon, to realize what was going on. But eventually, I got x-rays and I got an MRI showing I had spondylolisthesis with severe loss of disc height and–
Dr. Eric Chehab: And the spondylolisthesis, can you explain that once again?
Dr. Cary Templin: So that is where the top bone, which is L-5 slides forward. And what happened there is with that instability, the disc wears out quicker. So all my other disks in my back looked great. They’re in great shape. But as the, the way that I explained it is, the nerve roots come down the spinal canal and that’s like the highway, and then there’s exit ramps onto Dempster.
And so there’s a traffic jam on the exit ramp. The information is not going to get through, the cars can’t get through. And that’s what happens with the pinched nerve. So the exit ramp was being closed down because of this. We had to do is I did a, what’s called an anterior lumbar interbody fusion going in from the front.
And a spacer was placed that propped the two bones apart and opened up that exit ramp and my leg pain went away immediately. And so now I’m about a year and a half out, back to full activity, doing everything that I love to do. Funny story is I told a couple people that I was having it done, and I love to golf.
And we had talked about Tiger Woods and I said, this is going to take 10 strokes off my score. And they told me to do two or three levels, which I thought was pretty funny, so I could get even more off.
Dr. Eric Chehab: Okay. So, the last thing is where do you see the future of spine surgery and spinal fusion? Your background is also in motion-preserving surgery. The spinal fusion surgeries are incredibly successful, but what are some of the alternatives to even those types of procedures and where do you see the future of spine surgery? Let’s say 10 years down the road.
Dr. Cary Templin: There are motion-preserving procedures, which would mean placing, in most cases, a disc replacement device. They do them in the neck and some people do them in the lumbar spine.
Dr. Eric Chehab: So an artificial disc, you have to take the place of the worn out natural desk.
Dr. Cary Templin: It’s typically two pieces of metal that are pressed up against the bone with a plastic spacer. And that allows the neck or the low back to continue moving.
What we know in the neck is that we have FDA approval for two levels. And those studies have been shown to be as good or better in some cases than doing a fusion surgery. I think there will be more of a progression of that technology, however it’s not a panacea. Doing a disc replacement in someone who has extremely significant loss of height, is not feasible because you have to remove too much bone to decompress.
Dr. Eric Chehab: And then that device does fit it, that you can’t get it in to fit.
Dr. Cary Templin: It doesn’t fit her or you’re placing it in and you don’t have anything to support it. In the low back, 2005, I think the first disc replacement came out and there was a billion-dollar investment into it and it got pulled off the market rather quickly because it’s a less reproducible procedure than the neck, because it requires a more difficult exposure.
There are small pockets of people that are doing them that have excellent results, but it’s less of a reproducible procedure for sort of the general population.
Dr. Eric Chehab: And I think about the neck, boy, again, that anterior decompression and fusion in the neck is a hard surgery to beat, like it’s a very good surgery to begin with. And likewise with the lumbar spine, why is there a little bit more variability in the outcomes with lumbar spine surgery?
Dr. Cary Templin: If you just look at the tissue envelope around, you’ve got your abdomen, you’ve got all the big back muscles and there’s more disruption to the tissues. There’s more what I call collateral damage than doing the neck surgery.
When done minimally invasively, they have similar outcomes. But I think it’s the collateral damage that you see, also the lumbar spine is going to bear more weight. Right? If you look, your head weighs eight to 10 pounds, maybe, and that’s all the weight your neck is seeing, but if you look at your torso and everything, your lower back is seeing much more weight. Right. So there’s more stresses upon it.
Dr. Eric Chehab: It’s a tougher environment to begin with. Absolutely. So, though uncommon, what are some of the most common unfavorable outcomes from spinal fusion surgery?
Dr. Cary Templin: So when you look at the common outcomes, one of them would be continued pain, whether it be continued pain in your back or continued pain that radiates into your leg or arm.
When you look at continued pain in the back, for instance, it comes down to your indication for surgery. A lot of times, if you’re doing surgery on a degenerative disc disease, one level, I’m going to quote that patient’s success rate with significant improvement of their back pain of 70 to 75%.
That leaves a 25 to 30% chance that they may still have some significant back pain. So that’s why we don’t do that surgery as much as was done in the past.
When you’re looking at patients with continued pain, extending into the leg or into the arm, then you look at, okay, when this happens to me, which remarkably, it happens to everyone at some point, my first thing that I do is I get a CT scan. I want to look a CT scan, which shows me bone, and it shows me my screws and my spacers and everything really well. Number one, did I do a good job? Making sure everything is in right place.
Absolutely. I mean, you can have a malplaced screw. Some of this anatomy is so difficult to see on x-ray that sometimes the screws can breach.
Extremely rarely. That said, I check a CT scan to make sure that I’ve done a good job technically, then you look, and if they continue having pain, is it that the nerve was just so irritated before. Then I will get an MRI. I want to look at a new MRI and see, to make sure that I’ve done a good job decompressing the nerves. Sometimes when I put spacers in to try to decompress, or to take the pressure off the nerves by stretching everything out, it’s just not enough.
And those patients, I will have a conversation with. You may need to go back in, and I do tell them this beforehand, that there’s a two to 5% chance that you will need to have a formal decompression, where we actually do have to make another incision second operation of some sort, on a much smaller scale, just to specifically go in and open up a nerve. So these things happen and I think it comes down to the informed consent process, right? We tell the patient, ‘This is what we’re doing. This is why we’re doing it. And these are what the possibilities are.’ Then you look at down the road. If someone continues to complain of pain, six months down the road, um, there is a phenomenon called a non-union or a pseudoarthrosis, which means that we placed the bone graft in there.
Either put it in the disc space or on the sides of the spine to get the bones to grow together. And sometimes it doesn’t happen. If you look in the neck, if you look at a two level fusion of the neck, the non-union rate would be about 10%, which is not always symptomatic because once the nerves are open, even if the bones move a little bit, no problem, the nerves are happy. Correct. However, in the low back, for instance, because of the stresses it takes, if the bones actually don’t grow together, things can start to sort of settle in. Screws can loosen, and that can lead to pain, which may require another surgery. And again, this is something you talk about.
If you’re doing a poster lateral fusion, without a spacer in someone, the non-union rate on that surgery potentially could be 15, 20% at baseline. Then you got to look at the patient’s characteristics. What is their bone remodeling? If they are already what we call osteopenic or osteoporotic, will those patients have a lower turnover of bone?
And so they’re at a higher risk to develop such a problem. And this all goes into the planning of the surgery and the discussion with the patient about what you’re going to do. And then that brings you to what bone grafts you use. You can use the patient’s bone; you can use cadaver bone. There are synthetic bone graft substitutes.
We had talked about advances in spinal surgery over time. This is a big area where there’s a lot of research trying to figure out the best milieu of bone and other substrates to help the patient fuse, so that we can lower those rates of non-union.
Dr. Eric Chehab: And the most common favorable outcome is pain relief.
Dr. Cary Templin: Yeah. You get rid of someone’s leg pain or arm pain, and then on top of it, their low back pain, this is the majority of cases. And like we said, again, the right surgery done the right way with the right technique is going to be successful. And what I tell patients like for my surgery, I knew going in that I had a 95% chance of success with my surgery.
That’s a great number. And so if I can tell people that, based on what I see and what we have, there’s a very high likelihood. We had talked previously about injections and otherwise that we do, sometimes those injections are used for, not just therapeutic purposes, but also diagnostically. There was a study done that showed in the neck, if someone has a positive response to an epidural injection temporarily, for instance, where that pain goes away or significantly is diminished, and then has a neck surgery because the pain comes back after the injection wears off, that person has a 90% or higher success rate as opposed to having an injection with.
It puts them in about a 65% success rate. So we can use injections like that a lot of times to help us to nail down exactly where the problem comes from so that we know exactly where to operate and what to do.
Dr. Eric Chehab: So Cary, thank you so much for this overview. Before we end, are there any other things you’d like us to know about spinal fusion surgery?
Dr. Cary Templin: I think as we touched on briefly before, I think removing the stigma associated with spinal fusion surgery and understanding that if a spinal fusion is performed on the right patient with the right diagnosis, in the right manner, it is an extremely successful procedure, whether done in the neck or the lower back. The risk of major complications in the majority of these procedures such as neurologic injury causing weakness or numbness. Those are extremely, extremely low incidences. If you look at the improvement of quality of life, if you look at the improvement of pain scores and otherwise with a spinal fusion procedures done for the appropriate indication, it would absolutely be in favor of performing these procedures on the appropriate candidates.
Dr. Eric Chehab: My guest today is Dr. Cary Templin. Cary, thank you so much for taking the time to be with us.
Dr. Cary Templin: Eric, I really appreciate you having me here. I think that we hopefully have taken the mask off the monster of a spinal fusion today.