Episode 5 - Cutting Edge Surgery with Dr. Mark Smith
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Episode Summary
Correcting structural spinal problems involves techniques that will take years to practice and master for any neurosurgeon. Procedures not only need to effectively fix the issue, but make sure that no additional damage is done to adjacent areas, the skin and to the spine itself! Nowadays, patients are recommended a specific variety of surgery that does the job with lower risks compared to an open spine surgery.
This episode of Back Talk Doc features Dr. Mark Smith, a practitioner who has been with Carolina Neurosurgery & Spine Associates for 17 years, specializing in brain tumors, spine disorders and surgeries. He talks about what exactly Minimally Invasive Spine Surgery (MISS) involves and the many benefits it affords to patients with spinal issues.
While the risks are relatively the same as any open surgery, MISS, when performed correctly can help achieve the desired patient outcome without affecting the nearby areas or the spine overall. This is because prior to a diagnosis, the medical team will locate the specific location of the pathology that has an issue and focusing the treatment only in that spot. Additionally, there are lower pain levels, reduced risk for infection and quicker recovery times post-surgery.
Dr. Smith also explains how a patient can become a candidate for MISS, how soon can they get back to their regular activities after the procedure, and the downsides to this type of surgery. He also discusses the new technologies and techniques being studied today so doctors can improve the effectivity of MISS.
For Dr. Smith, it’s also important that you consult with a clinic that’s able to offer you a comprehensive variety of techniques that can help you have a better patient outcome.
Key Moments In The Episode
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia dives into how using a far-infrared sauna promotes wellness and offers a range of health benefits that can help you stay active. Using this piece of equipment not only helps improve blood circulation and tissue oxygenation, it also eliminates toxins and cleanses your body, to name a few. (06:52)
Links Mentioned In The Episode
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Correcting structural spinal problems involves techniques that will take years to practice and master for any neurosurgeon. Procedures not only need to effectively fix the issue, but make sure that no additional damage is done to adjacent areas, the skin and to the spine itself! Nowadays, patients are recommended a specific variety of surgery that does the job with lower risks compared to an open spine surgery.
This episode of Back Talk Doc features Dr. Mark Smith, a practitioner who has been with Carolina Neurosurgery & Spine Associates for 17 years, specializing in brain tumors, spine disorders and surgeries. He talks about what exactly Minimally Invasive Spine Surgery (MISS) involves and the many benefits it affords to patients with spinal issues.
While the risks are relatively the same as any open surgery, MISS, when performed correctly can help achieve the desired patient outcome without affecting the nearby areas or the spine overall. This is because prior to a diagnosis, the medical team will locate the specific location of the pathology that has an issue and focusing the treatment only in that spot. Additionally, there are lower pain levels, reduced risk for infection and quicker recovery times post-surgery.
Dr. Smith also explains how a patient can become a candidate for MISS, how soon can they get back to their regular activities after the procedure, and the downsides to this type of surgery. He also discusses the new technologies and techniques being studied today so doctors can improve the effectivity of MISS.
For Dr. Smith, it’s also important that you consult with a clinic that’s able to offer you a comprehensive variety of techniques that can help you have a better patient outcome.
Key Moments In The Episode
- How to stay on top of your game as a neurosurgeon - 04:07
- Basics of Minimally Invasive Spine Surgery or MISS - 13:18
- Tools typically used in MISS - 16:22
- Benefits of MISS versus an open procedure - 18:19
- Standard recovery times - 23:03
- MISS for correcting cervical spine issues - 25:50
- Downsides to MISS - 27:05
- Use of lasers as standard of care in neurosurgery - 28:52
- Success rates of standard MISS surgeries - 29:41
- Possible insurance hurdles - 30:51
- New technologies - 32:58
- Using robotics in MISS - 34:41
- Important factor in deciding to go for MISS - 35:44
Every episode of Back Talk Doc includes a Health Matters segment intended to provide actionable health information you can immediately put into practice in your life. This week, Dr. Lakhia dives into how using a far-infrared sauna promotes wellness and offers a range of health benefits that can help you stay active. Using this piece of equipment not only helps improve blood circulation and tissue oxygenation, it also eliminates toxins and cleanses your body, to name a few. (06:52)
Links Mentioned In The Episode
- High Tech Health
- Detoxify or Die by Sherry Rogers M.D.
- Far infrared radiation (FIR): its biological effects and medical applications
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Intro: 00:01 Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health, brought to you by Carolina Neurosurgery and Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 00:35 Welcome to Back Talk Doc episode five. I am your host, Dr. Sanjiv Lakhia, a board certified specialist in physical medicine and rehabilitation at Carolina Neurosurgery and Spine Associates located in Charlotte, North Carolina. Today we're going to discuss a topic that I term as cutting edge, and that is minimally invasive spine surgery. It deals with how to have surgery in a way that promotes a quick recovery time and gets you back on track. So I appreciate you taking time today to tune in. We have a very special guest. So I want to welcome to the show Dr. Mark Smith. Mark, welcome to the show.
Mark Smith: 01:12 Thank you, Sanjiv.
Sanjiv Lakhia: 01:13 Mark comes to us with a background in minimally invasive spine surgery. He did medical school at the Medical College of Georgia and residency at the University of Tennessee, and has been in practice at our group for about 17 years. And I think he's a perfect person to help clear up some of the confusion out there on minimally invasive spinal techniques and provide you with up-to-date information so you can make proper decisions for your healthcare. Before we dive into today's topic, though, Mark, I'd like for you to share with our listeners a little bit about what attracted you to the field of neurosurgery.
Mark Smith: 01:44 Sure. In our training program at Medical College of Georgia, we were actually forced to do either a neurosurgery or a neurology rotation, and prior to that I really had no exposure to the field. So in my neurosurgery rotation, I was exposed to the operative procedures and the types of patients that they were really inspiring to me and very interesting, and I was hooked at that point. So throughout the rest of my training, I took extra rotations and did additional work that confirmed my desire to do that. So compared to some people who know what they want to do early in their education, I came to neurosurgery fairly late.
Sanjiv Lakhia: 02:29 I myself started out with a career in engineering, and then ended up in medicine, so I can understand how things take time to evolve. But it looks like you haven't looked back since you made that decision, to all of our benefit. Within the field of neurosurgery, you do a lot. I've worked with you for a while now, and you don't just do spine surgery, you do a lot of brain surgery, and you're involved in many different things. Have you developed any favorite conditions or surgeries you like to treat or perform at this point?
Mark Smith: 02:58 You're right. In our practice, sub-specialized within the field, so I have two subspecialties. One is minimally invasive spine, which is obviously what we're covering today. Then also cranial oncology, and I like each of those for different reasons. Minimally invasive spine allows me to have a positive impact on a patient with minimal morbidity, and usually the interactions are fairly quick and definitive, and I've enjoyed the benefit that I've been able to provide for patients in that arena.
Mark Smith: 03:37 It's difficult to pick one particular surgical intervention, though. Honestly, I think at this point in my career it really comes down to the interaction I have with the patients. So there are a lot of different procedures that will improve a patient's lifestyle, or their prognosis even. So I honestly enjoy more of that interaction than one specific procedure over another.
Sanjiv Lakhia: 04:07 You guys do amazing work. You're being very humble. As a neurosurgeon there's days where I know you're saving lives and having a dramatic influence on a patient as well as their family and their quality of life. So what are the daily habits or techniques that you employ to stay on top of your game and functioning at a high level? Because obviously neurosurgery is a very high stress field.
Mark Smith: 04:30 You're right. We tend to minimize that as surgeons, and not necessarily appreciate the stresses that we're under. But as we take a step back and the 10,000 foot view is there's a fair amount of physical demands on us during surgery. We're on our feet for long hours at a time, do multiple operations in a day. We're under a lot of mental stress at the time as well, and a lot of the problems that we take care of are very significant for patients and cause a lot of stress and anxiety among the patients, and that increases their concern and their family's concern. So while we tend to get used to dealing with these scenarios, we forget the impact it has on us and our bodies, and there's a fair amount of stress and burnout in the surgical field. You know, neurosurgery not alone, but all the surgical field.
Mark Smith: 05:29 So personally, I use exercise as a good stress relief. So multiple times a week I'll go for a jog or get on the treadmill or do a light workout with weights. Even 20 or 30 minutes is enough to help me reset at the end of the day. Good exercise keeps me going, honestly. Diet is critical also, and by paying attention to what I eat and how I treat my body, I've been able to stay relatively healthy over the last 17 years.
Sanjiv Lakhia: 06:07 On Back Talk Doc, those of you who know me understand how passionate I am about promoting wellness in our patient population, and I ask this question just to give listeners insight into - there are different ways to accomplish this. In my last interview with Dr. Joe Cheadle, he had a bit of a morning routine that he would start his day with, with some sort of physical exercise such as the Peloton bike, or Orangetheory or yoga. And Mark just illustrated here that he at times will fit it into the afternoon or evening. And it really doesn't matter, folks, when you do it. It's just staying consistent with it, and it'll help you handle the stress of your life no matter what profession that you're in. So thanks for sharing those tips with us, Mark. And we're going to take a quick break.
Sanjiv Lakhia: 06:52 On today's Health Matters segment, I'd like to discuss with you a technique that I utilize in my wellness plan to promote my overall health and fitness, and that is the use of a far infrared sauna. Sauna therapy has a growing body of research to support its benefits to promote wellness in many, many ways. I often share with my patients that I myself have suffered from low back pain from time-to-time, secondary to a bulging disk in my low back. And I believe my routine use of a far infrared sauna has really helped keep me active and on track with work and my exercise and fitness goals. About 10 years ago I purchased a far infrared sauna from High Tech Health, and they make fabulous saunas, and we'll link to that company in our show notes today. But I want to briefly review with you some of the science behind the use of far infrared sauna and how it might benefit your health situation.
Sanjiv Lakhia: 07:51 By way of introduction, infrared radiation is an invisible form of electromagnetic energy and the wavelength of which is longer than that of visible light. So infrared radiation can be categorized into different groups according to the wave length, and it's namely categorized into near infrared, middle infrared, and far infrared based upon where it stands in the spectrum. So infrared radiation enables multiple forms of energy to be transferred into subcutaneous tissue, that is through your skin and into the fat, at approximately three centimeters deep penetration. And this can be done without excessive heating of the skin surface, so you're able to avoid thermal burns, which is a significant benefit. So if you use far infrared therapy, you can have improvement in your blood flow and tissue oxygenation on a far greater level than a traditional sauna. And the difference between traditional saunas and far infrared sauna is that a traditional sauna essentially will heat and humidify the air to turn the air warm, which then in turn warms your body. Far infrared saunas use light to create the heat and only heats about 20% of the air, leaving 80% of the heat available to heat your body. So it's a more efficient way of generating increased temperatures internally, and then you can benefit from that in many ways.
Sanjiv Lakhia: 09:10 So what are the benefits? Well, there's several. Research has indicated that several mechanism of action exist that promote wellness. Number one, sauna therapy improves peripheral blood flow. Number two, it improves endothelial function. Endothelial function is the function of the lining of your arteries, and this has broad implications in the fields of cardiovascular disease, diabetes, along with kidney disease. More specifically with regards to pain, increasing circulation in the soft tissues and the muscles can help remove byproducts of metabolism that play a role with pain and lower your pain levels.
Sanjiv Lakhia: 09:52 Far infrared sauna has been shown that it lowers oxidative stress in the body and this in turn can also reduce your development of atherosclerosis and heart failure. And in particular, the research is quite interesting with congestive heart failure, as it appears far infrared sauna treatments can reduce the preload or the work on the heart and help people have better quality of life with less shortness of breath. Research has shown it can be helpful for diabetics as well. One article that I read shows that after four weeks of treatment with far infrared therapy administered to the feet, that type two diabetics showed a significant reduction in cortisol levels and blood glucose levels, so that's quite remarkable.
Sanjiv Lakhia: 10:32 The other area where using a sauna on a routine basis can be quite helpful is in the field of detoxification. Dr. Sherry Rogers wrote a book called Detoxify or Die, and it's quite striking in its nature, but she does go over some interesting information with regards to how you can use certain sauna protocols to cleanse your body and protect against environmental exposures. What environmental exposures, you may ask? Well, we are all exposed day-to-day with regards to paint, toys, window shades, tattoos, fabric softeners, tuna and swordfish are known to have mercury levels. Our water can be dirty. Even the cookware we use; gasoline, on and on. There's many ways that we can be exposed to heavy metals such as mercury and lead, and these heavy metals will deposit in our tissues, our bones and our fat, and the research has proven that through systematic use of a far infrared sauna, you can mobilize these toxins and they can be excreted through your sweat and through your urine and through your bowel. So it's a tremendous way to promote wellness and purify your body.
Sanjiv Lakhia: 11:42 If you're considering using a far infrared sauna, you should keep in mind a few things. Number one, you want to go very slow. High Tech Health, when we purchased ours, they gave us a protocol where you start with as little as five minutes at a low temperature, and over the course of a month build up your time and exposure. You can experience some initial headache and detoxification type side effects, so you don't want to rush into sauna treatment.
Sanjiv Lakhia: 12:03 Number two, you have to see very well hydrated. So when I'm in my sauna, I typically have a fairly tall glass of water, and I use electrolyte drops in the water to maintain my potassium and magnesium levels, and that's the third consideration. A lot of people who do sauna therapy forget to rehydrate and supplement with minerals that are necessary so you don't develop any mineral deficiencies.
Sanjiv Lakhia: 12:26 If you Google this, there are more exotic detoxification protocols I don't really want to get into, but one way to get the most benefit of the sauna is to do a little bit of exercise before you get in. This will increase circulation in your tissues, open up your capillaries and allow for a better effect of the sauna. So I typically do my sauna treatments after I've done a bit of cardio or some circuit training. So as I sat in my sauna this morning, I couldn't help but notice how relaxing the effect is. It really helps with stress and with pain reduction. If you get a chance to trial a sauna, even a dry sauna at the gym, please do. It can be a valuable tool in your toolbox to dealing with your back pain or other orthopedic injuries.
Sanjiv Lakhia: 13:08 Let's dive into today's topic, which is minimally invasive spine surgery. Can you define for our listeners what exactly minimally invasive spine surgery is, or as we call it, MISS?
Mark Smith: 13:18 I can tell you how I define it, and there's some confusion around what is legitimate minimally invasive spine surgery. We know there are certain structural problems in the spine that when corrected will help a patient feel better or function better, have less pain, have improved strength, those types of improvements in nerve function. So minimally invasive surgery would be one where we accomplish those structural changes, the same ones that would be accomplished with an open surgery, but do those with less trauma to the body. In other words, instead of making a six inch incision and directly visualizing all the spine structures, we make a one inch incision or a two centimeter incision and only visualize a portion of the spine that needs to be corrected. And in doing so, we cause significantly less trauma to the musculature and create less morbidity, which means damage when we do the procedure.
Mark Smith: 14:28 Now, I don't believe that all minimally invasive spine surgery is the same. So if you hear of a procedure described as a minimally invasive procedure that turns out to be minimally effective, well then to me that's not true minimally invasive spine surgery. And there's some mimickers out there and some procedures that may seem attractive because they don't seem like they carry much morbidity at all that turn out to be minimally effective, and I'd stay away from those procedures.
Sanjiv Lakhia: 15:08 Are you able to give us a little more specifics on that? If I'm a patient out there with a herniated disk and I think I need surgery, are there certain procedures that you personally would say guard against?
Mark Smith: 15:18 Sure. So a herniated disk is a piece of firm cartilage pushed out from the disk against the nerve root, and that piece of disk material needs to be removed for the pressure on the nerve to be resolved. So a laser procedure, or a heating procedure, or even some type of endoscopic decompressions don't adequately accomplish that, so there needs to be a certain amount of exposure at the time of surgery to accomplish that goal, and if that's not allowed by the procedure, then I would consider that a reasonable minimally invasive operation.
Sanjiv Lakhia: 16:05 And on this show, I really try and break it down into simple, easy to understand terms and definitions. Minimally invasive spine surgery. So if you don't make a big incision, how are you able to see what you need to see? What are kind of the tools that are utilized during the procedure?
Mark Smith: 16:21 Sure. So in every minimally invasive spine surgery, we use a live x-ray machine called fluoroscopy. So we know based on the preoperative imaging where the pathology is, and we localize that with an x-ray, and we guide our tools toward that area of pathology using the x-ray, so we have confirmation that we're in the right location and that location correlates to what we see on the MRI. And in most cases, we have specially designed instruments that we use with a camera or a microscope to visualize a small area of anatomy to make it look larger so that we can conduct the same type of technical procedural aspects to that we would in a larger open surgery.
Sanjiv Lakhia: 17:15 So it's really leveraging tools and technology to provide the surgeon with as much information they need while performing the least invasive or least damaging procedure to get that information, which is similar ... Would you say it's similar to orthopedics? How they, again, using arthroscopy to look in shoulders and then that evolved to looking in hips, and it's a similar concept for individuals to understand that in the world of spine surgery we try and do as little as we have to to accomplish the goal.
Mark Smith: 17:46 That's a great way to think about it, and minimally invasive spine surgery has followed a lot of the surgical subspecialties, general surgery, orthopedics, cardiology, so we honestly have a shorter history in spine surgery than those other specialties do.
Sanjiv Lakhia: 18:06 And you covered this a little bit earlier, the benefits, can you list those again in terms of a minimally invasive procedure versus an open procedure? Is it predominantly the benefit is in the recovery time?
Mark Smith: 18:19 Sure. There are a couple of very well-defined and proven benefits of minimally invasive surgery, and I'll just list a couple of those. There's less blood loss during surgery, there's less postoperative pain, shorter hospital stays are very common, reduced need for a blood transfusion, and probably one of the most important, particularly in spinal fusion surgery, there's a lower infection rate. Now, those of us that do these procedures commonly also feel that the adjacent segments to the segment that we operate on are placed under less stresses postoperatively after a fusion. So, that decreases the disease that may develop in an adjacent segment over the years after the surgery. Now that we think is correct, but we haven't fully proven that. Most minimally invasive spine surgeons believe it, and I tell my patients that's likely the case too. So those benefits are obviously great, but only if the surgery itself is effective. A short one hour surgery that doesn't exact the benefit that we're trying to accomplish is not better for a patient than a two hour surgery that requires a hospital stay.
Sanjiv Lakhia: 19:46 If you have a patient in the office who comes in and you're pretty convinced that they have a disk issue, and maybe some instability that's contributing to their back and leg pain, how do you as a neurosurgeon kind of process that information and make a determination about whether or not they're a candidate for a minimally invasive approach versus an open approach?
Mark Smith: 20:07 We define that in a couple of ways. The more focal the pathology is, the more likely a minimally invasive approach will work. Now, the question of instability involves some judgment. We use dynamic x-rays to look at the movement of the spine in different positions, and if there is abnormal motion on, say, flexion-extension x-rays, occasionally we are required to do stabilization as a part of the procedure, but that's always a conversation I have with the patients in front of their imaging, and we occasionally will have two options for surgery. If there's some indication that the instability is mild, then a fusion may be avoided, at least for the short term, and many patients will opt for a smaller procedure initially with close monitoring and follow up.
Mark Smith: 21:05 And I should mention, we also are very diligent about diagnosis in minimally invasive spine surgery. We're doing very focal operations typically involved in the treatment of a limited number of nerve roots. So, pain in the leg has to be very defined to one or two nerve root distributions for us to be as confident that patients are going to respond well to surgery. So I take additional time in the office, and as you know, order additional testing if there's any question regarding what the pain generator is, and even diagnostic injections occasionally to predict what the outcome of surgery will be. And when we take that extra time, we increase the specificity of our diagnosis and we're more able to predict surgical outcome for our patients.
Sanjiv Lakhia: 22:01 What Mark just described is the reason why, if you were to come to our practice with a condition in your back, that you will frequently be questioned whether or not the symptoms are going down your leg, and is it going in a specific location? We try to narrow down as close as we can the exact pain generator, which also may be a reason why if you have diffused pain, meaning pain all across your back, down both your legs, that's very hard to pinpoint based upon the day or the activity why there may be more hesitancy to have surgery performed, and more specifically minimally invasive procedure. So what he spoke to there, folks, is the ability to really hone in on the diagnosis, figure out exactly what the problem is, and if we can do that, then your odds of having successful outcomes with surgery or nonsurgical care definitely will go up.
Sanjiv Lakhia: 22:50 You mentioned this before a little bit, but cover again: standard recovery times. So people want to know, "Hey, when I get the surgery, how long am I under? And then how long before I can either get back to work and then how long if I can get back to athletic activities?"
Mark Smith: 23:03 I'll break that down into two different categories. One category would be minimally invasive diskectomy or laminectomy, and the other is minimally invasive fusion. So for diskectomy or laminectomy, patients may require some pain medication for a day or two. They're immediately mobilized after surgery. They're kept at light activity, which means reduced lifting, walking program for the first four weeks, and then they're placed in physical therapy with a return to full activity between eight and 12 weeks postoperatively, depending on their progress with physical therapy and their desired activity. I obviously assume a wrestler's going to be on a different plan than a couch potato.
Mark Smith: 23:51 Now, for a lumbar fusion, I extend that by a couple of months, so same walking program for the first four weeks. Typically a little more in the way of pain medication for the first two to four weeks, and then physical therapy lasting four to six weeks, usually finishing up by 12 weeks post-op. Full activity for a fusion can occur between three and six months, depending on what the specific activity is. Golfers, tennis players, runners, more active patients require more time. That's not necessarily to let the surgical site heal, but to strengthen the areas around the surgery. Techniques that we use to do a stabilization or fusion surgery provide significant amount of stability in the region of our operation, but that does create some stresses on the segments above and below, so we want patients to be strong in their core and flexible before obtaining their most strenuous activity.
Sanjiv Lakhia: 25:01 We're recording the podcast today in Ballantyne, which is a suburb of Charlotte, and we're in a corporate park, so we see a lot of corporate workers, bankers, people with more sedentary desk type work. For those folks who have the minimally invasive diskectomy or laminectomy, how quickly can you release some typically back to work?
Mark Smith: 25:22 A lot of patients begin to work from home right away. Some probably, against the best advice, are back to work within a week.
Sanjiv Lakhia: 25:31 Sure. Yeah.
Mark Smith: 25:33 Physicians included in that category. Usually one to two weeks for most people.
Sanjiv Lakhia: 25:39 I get a lot of golfers who come in and they want to get right back on the course within a day or two. So there is some expectation setting that has to happen, so thanks for sharing that information with the listeners.
Mark Smith: 25:49 Sure.
Sanjiv Lakhia: 25:50 Most of what we discussed today has primarily focused on the low back. Are there also minimally invasive techniques that are utilized in the cervical spine to treat pinched nerves? Ruptured disks?
Mark Smith: 26:00 There are great options. The options are slightly less in number than what we have for the lumbar spine because of the anatomy of the cervical spine. In the cervical spine, the bone surrounds the spinal cord, and the spinal cord itself cannot be manipulated. So if there's anatomic pathology that causes compression of the spinal cord or compromises the canal, or ring of bone that surrounds the spinal cord, then minimally invasive surgery may not be an option. But for the typical herniated disk with arm pain, unilateral arm pain specifically, there are great posterior cervical procedures that have been performed for many years here with great success.
Sanjiv Lakhia: 26:49 Posterior? You mean from the back?
Mark Smith: 26:51 That's correct.
Sanjiv Lakhia: 26:52 When you do the minimally invasive techniques, are there any downsides? Does it affect the risk of a disk re-herniating? Does it create more scar tissue? Or is all of that just better because you're doing less damage to the tissue?
Mark Smith: 27:05 So if a minimally invasive surgery is done correctly, then you're accomplishing the same structural benefit that you would in a large or open surgery. So the risks in general should be the same. Now, the more technically demanding minimally invasive procedures have to be learned and should be learned in a fellowship or a program that has a lot of volume, because there is a learning curve to the procedures, but an experienced minimally invasive surgeon's risk profile should be no different than a typical open surgery. I did notice earlier in my career, because there is very little postoperative pain from the surgery itself, that patients sometimes are too active after surgery, and increased activity, increased stress on the spine can create a scenario where a disk can re-herniate or a patient can injure the site of surgery. So I'm diligent with patients about their activity postoperatively so they heal appropriately.
Sanjiv Lakhia: 28:18 You touched earlier on laser surgery, mentioned that briefly. I got to tell you, it's probably the number one question I get in the office and have for years for various reasons, and I don't really necessarily want to get into the history of the Laser Surgery Institute and all that that surrounds it, but I would like to get your opinion just on, are lasers utilized as a standard of care within the field of neurosurgery? And if so, in what capacity? And if not, then why not?
Mark Smith: 28:52 The short answer is no. Lasers are not used, and I may be one of the only neurosurgeons around who has actually seen a laser used in surgery. We actually, in residency, occasionally use the laser to resect certain types of spinal tumors. So surgeries generate heat, they cauterize tissue, or shrink it, or stop bleeding. That's what a laser does, and that is useful in some tumor surgeries, or was years ago, and now we have better techniques to use. So there really is no laser that we can point at the disk and create any kind of improvement for a patient. It turns out just to be really a catchy term.
Sanjiv Lakhia: 29:41 But I think it speaks to patients' desire to have a surgery that is less invasive with quick recovery times. Would you say it's a fair statement that the standard minimally invasive spine techniques that are offered now can really accomplish those things that patients are looking for?
Mark Smith: 29:59 They most certainly can, and patients should know, when you see a surgeon or see me, I can give you my experience. I'm going to design the surgery, if it's appropriate, that'll take care of the problem and make a patient feel better. And the last thing that I want to do is operate on a condition that I know is unlikely to improve or to stretch the indications for surgery beyond what could be effective.
Sanjiv Lakhia: 30:30 That's fantastic. Okay. Moving on to our last couple of questions. Again, we're here with Dr. Mark Smith. I really appreciate his time, and he's helping educate us on minimally invasive spine surgery. Are there insurance hurdles or things that have to be done by the patient before we can offer them minimally invasive spine techniques?
Mark Smith: 30:51 So most diskectomies or laminectomies are typically easy to be approved by insurance companies, and particularly in our practice because we have a focus on conservative care, so patients have typically received appropriate nonoperative therapy by the time that they're evaluated by the surgeon. Now, minimally invasive surgery as we define it is not controversial, so we're not doing procedures that are not well accepted or outside the box, so those are the types of things that insurance companies can be less enthusiastic about.
Mark Smith: 31:32 Now, in regard to fusion, there is some additional documentation that's required, because fusion surgery is more expensive, and for an insurance company they require more justification to perform the procedure. In our indications, in this practice, there's typically not an issue with having approval by an insurance company for that type of procedure, but it may require additional documentation.
Mark Smith: 32:04 Patients do have increased responsibility when it comes to fusion surgery. There is typically some rigidity about the amount of conservative therapy that's required. Patients do need to stop smoking if they smoke, and weight loss may be required as well. But since we operate well within the standard of care, if we deem a patient a surgical candidate, they're typically approved, even though it may take some additional work.
Sanjiv Lakhia: 32:32 And by the way, all the things he just mentioned, the weight loss, smoking cessation, these are going to help you recover from surgery, they're going to decrease your risk of infection, and really just improve your outcome. So I think there's reasons why those are emphasized when they're offering you surgery.
Sanjiv Lakhia: 32:50 And moving on to our last question, Mark, are there any new technologies on the horizon in the field of minimally invasive spine surgery that gets you excited?
Mark Smith: 32:58 Well, I think we're in kind of the golden age of spine surgery at this point. I trained in Memphis, and one of my mentors really sparked the modern minimally invasive spine revolution, so I was lucky enough to be on the front end of that, and that's certainly been to my advantage in practice. Almost any surgical approach you can imagine has a minimally invasive option at this point, and as we grow in our understanding of what pathologies are best treated with certain techniques, we're going to continue to see better tools developed by spinal instrumentation companies, better approaches developed by our general surgery colleagues, and further improvement in morbidity that we create for our patients. Now, honestly, the holy grail to spinal issues would be a biological solution such that we could prevent the degenerative change that occurs in the disk, and while there are always studies ongoing about that, we're not quite on the cusp of figuring that one out yet.
Sanjiv Lakhia: 34:18 And on future episodes, I'm lining up some people where we can have a discussion about the status of stem cells and PRP, and the new biologic agents that are out there from a nonsurgical perspective. Dr. Cheadle mentioned on our previous podcast robotics. Do robotics fall under the umbrella of minimally invasive spine surgery?
Mark Smith: 34:41 They do. A robot can be used in an open spine operation or a minimally invasive operation. The robot follows a navigation plan that you create based on the patient's unique anatomy, and we benefit from specialized directional devices used in the operating room, and even interoperative CT scan. So our techniques have evolved because of those, and radiation exposure to both the patient and the surgeon has been diminished, but they still don't replace experience and skill at this point. What we see on the computer screen has to match with what our anticipation of the anatomy is and our surgical feel for the bony anatomy. So there are a significant number of technological advances, but they have to be married to a skillset as well.
Sanjiv Lakhia: 35:44 And Mark, I know there's one more point that you wanted to make to our listeners with regards to their decision making process for minimally invasive spine surgery or spine surgery of any type.
Mark Smith: 35:55 That's right. I think it is most beneficial for patients to go to a surgeon or group that offers all techniques, such that there is no bias instilled into the visit based on the surgeon's capabilities or surgeon's partner's capabilities or technique. So by having a comprehensive set of procedures available, we're able to make the best choice for the patient without any type of bias. My mentor described minimally invasive spinal instrumentation as ship in a bottle surgery, and as I was a kid and thought back to seeing pieces of art where entire ships were constructed inside a glass bottle, it really made a lot of sense and connected with me. So we're creating an instrumentation in a patient's spine without creating significant damage in the skin, and without essentially breaking the bottle that is the structure of the spine.
Sanjiv Lakhia: 37:09 That's a terrific explanation. I appreciate you sharing that. Well, there you have it folks. You're not going to find a better breakdown with regards to minimally invasive spine surgery, the ins and outs, than what Dr. Mark Smith just provided for you today. He covered quite a bit, helped define it for us, went through the indications and the risks, discussed recovery times. He discussed even downsides and how they decide between open and less invasive procedures. So Mark, I really appreciate your time today. I think this is going to be very informative to the listeners, to our patients, and clearing up some confusion that's out there with regards to this topic. So once again, thank you so much for taking the time today.
Mark Smith: 37:48 You're welcome. I enjoyed being here.
Outro: 37:50 Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available carolinaneurosurgery.com.
Sanjiv Lakhia: 00:35 Welcome to Back Talk Doc episode five. I am your host, Dr. Sanjiv Lakhia, a board certified specialist in physical medicine and rehabilitation at Carolina Neurosurgery and Spine Associates located in Charlotte, North Carolina. Today we're going to discuss a topic that I term as cutting edge, and that is minimally invasive spine surgery. It deals with how to have surgery in a way that promotes a quick recovery time and gets you back on track. So I appreciate you taking time today to tune in. We have a very special guest. So I want to welcome to the show Dr. Mark Smith. Mark, welcome to the show.
Mark Smith: 01:12 Thank you, Sanjiv.
Sanjiv Lakhia: 01:13 Mark comes to us with a background in minimally invasive spine surgery. He did medical school at the Medical College of Georgia and residency at the University of Tennessee, and has been in practice at our group for about 17 years. And I think he's a perfect person to help clear up some of the confusion out there on minimally invasive spinal techniques and provide you with up-to-date information so you can make proper decisions for your healthcare. Before we dive into today's topic, though, Mark, I'd like for you to share with our listeners a little bit about what attracted you to the field of neurosurgery.
Mark Smith: 01:44 Sure. In our training program at Medical College of Georgia, we were actually forced to do either a neurosurgery or a neurology rotation, and prior to that I really had no exposure to the field. So in my neurosurgery rotation, I was exposed to the operative procedures and the types of patients that they were really inspiring to me and very interesting, and I was hooked at that point. So throughout the rest of my training, I took extra rotations and did additional work that confirmed my desire to do that. So compared to some people who know what they want to do early in their education, I came to neurosurgery fairly late.
Sanjiv Lakhia: 02:29 I myself started out with a career in engineering, and then ended up in medicine, so I can understand how things take time to evolve. But it looks like you haven't looked back since you made that decision, to all of our benefit. Within the field of neurosurgery, you do a lot. I've worked with you for a while now, and you don't just do spine surgery, you do a lot of brain surgery, and you're involved in many different things. Have you developed any favorite conditions or surgeries you like to treat or perform at this point?
Mark Smith: 02:58 You're right. In our practice, sub-specialized within the field, so I have two subspecialties. One is minimally invasive spine, which is obviously what we're covering today. Then also cranial oncology, and I like each of those for different reasons. Minimally invasive spine allows me to have a positive impact on a patient with minimal morbidity, and usually the interactions are fairly quick and definitive, and I've enjoyed the benefit that I've been able to provide for patients in that arena.
Mark Smith: 03:37 It's difficult to pick one particular surgical intervention, though. Honestly, I think at this point in my career it really comes down to the interaction I have with the patients. So there are a lot of different procedures that will improve a patient's lifestyle, or their prognosis even. So I honestly enjoy more of that interaction than one specific procedure over another.
Sanjiv Lakhia: 04:07 You guys do amazing work. You're being very humble. As a neurosurgeon there's days where I know you're saving lives and having a dramatic influence on a patient as well as their family and their quality of life. So what are the daily habits or techniques that you employ to stay on top of your game and functioning at a high level? Because obviously neurosurgery is a very high stress field.
Mark Smith: 04:30 You're right. We tend to minimize that as surgeons, and not necessarily appreciate the stresses that we're under. But as we take a step back and the 10,000 foot view is there's a fair amount of physical demands on us during surgery. We're on our feet for long hours at a time, do multiple operations in a day. We're under a lot of mental stress at the time as well, and a lot of the problems that we take care of are very significant for patients and cause a lot of stress and anxiety among the patients, and that increases their concern and their family's concern. So while we tend to get used to dealing with these scenarios, we forget the impact it has on us and our bodies, and there's a fair amount of stress and burnout in the surgical field. You know, neurosurgery not alone, but all the surgical field.
Mark Smith: 05:29 So personally, I use exercise as a good stress relief. So multiple times a week I'll go for a jog or get on the treadmill or do a light workout with weights. Even 20 or 30 minutes is enough to help me reset at the end of the day. Good exercise keeps me going, honestly. Diet is critical also, and by paying attention to what I eat and how I treat my body, I've been able to stay relatively healthy over the last 17 years.
Sanjiv Lakhia: 06:07 On Back Talk Doc, those of you who know me understand how passionate I am about promoting wellness in our patient population, and I ask this question just to give listeners insight into - there are different ways to accomplish this. In my last interview with Dr. Joe Cheadle, he had a bit of a morning routine that he would start his day with, with some sort of physical exercise such as the Peloton bike, or Orangetheory or yoga. And Mark just illustrated here that he at times will fit it into the afternoon or evening. And it really doesn't matter, folks, when you do it. It's just staying consistent with it, and it'll help you handle the stress of your life no matter what profession that you're in. So thanks for sharing those tips with us, Mark. And we're going to take a quick break.
Sanjiv Lakhia: 06:52 On today's Health Matters segment, I'd like to discuss with you a technique that I utilize in my wellness plan to promote my overall health and fitness, and that is the use of a far infrared sauna. Sauna therapy has a growing body of research to support its benefits to promote wellness in many, many ways. I often share with my patients that I myself have suffered from low back pain from time-to-time, secondary to a bulging disk in my low back. And I believe my routine use of a far infrared sauna has really helped keep me active and on track with work and my exercise and fitness goals. About 10 years ago I purchased a far infrared sauna from High Tech Health, and they make fabulous saunas, and we'll link to that company in our show notes today. But I want to briefly review with you some of the science behind the use of far infrared sauna and how it might benefit your health situation.
Sanjiv Lakhia: 07:51 By way of introduction, infrared radiation is an invisible form of electromagnetic energy and the wavelength of which is longer than that of visible light. So infrared radiation can be categorized into different groups according to the wave length, and it's namely categorized into near infrared, middle infrared, and far infrared based upon where it stands in the spectrum. So infrared radiation enables multiple forms of energy to be transferred into subcutaneous tissue, that is through your skin and into the fat, at approximately three centimeters deep penetration. And this can be done without excessive heating of the skin surface, so you're able to avoid thermal burns, which is a significant benefit. So if you use far infrared therapy, you can have improvement in your blood flow and tissue oxygenation on a far greater level than a traditional sauna. And the difference between traditional saunas and far infrared sauna is that a traditional sauna essentially will heat and humidify the air to turn the air warm, which then in turn warms your body. Far infrared saunas use light to create the heat and only heats about 20% of the air, leaving 80% of the heat available to heat your body. So it's a more efficient way of generating increased temperatures internally, and then you can benefit from that in many ways.
Sanjiv Lakhia: 09:10 So what are the benefits? Well, there's several. Research has indicated that several mechanism of action exist that promote wellness. Number one, sauna therapy improves peripheral blood flow. Number two, it improves endothelial function. Endothelial function is the function of the lining of your arteries, and this has broad implications in the fields of cardiovascular disease, diabetes, along with kidney disease. More specifically with regards to pain, increasing circulation in the soft tissues and the muscles can help remove byproducts of metabolism that play a role with pain and lower your pain levels.
Sanjiv Lakhia: 09:52 Far infrared sauna has been shown that it lowers oxidative stress in the body and this in turn can also reduce your development of atherosclerosis and heart failure. And in particular, the research is quite interesting with congestive heart failure, as it appears far infrared sauna treatments can reduce the preload or the work on the heart and help people have better quality of life with less shortness of breath. Research has shown it can be helpful for diabetics as well. One article that I read shows that after four weeks of treatment with far infrared therapy administered to the feet, that type two diabetics showed a significant reduction in cortisol levels and blood glucose levels, so that's quite remarkable.
Sanjiv Lakhia: 10:32 The other area where using a sauna on a routine basis can be quite helpful is in the field of detoxification. Dr. Sherry Rogers wrote a book called Detoxify or Die, and it's quite striking in its nature, but she does go over some interesting information with regards to how you can use certain sauna protocols to cleanse your body and protect against environmental exposures. What environmental exposures, you may ask? Well, we are all exposed day-to-day with regards to paint, toys, window shades, tattoos, fabric softeners, tuna and swordfish are known to have mercury levels. Our water can be dirty. Even the cookware we use; gasoline, on and on. There's many ways that we can be exposed to heavy metals such as mercury and lead, and these heavy metals will deposit in our tissues, our bones and our fat, and the research has proven that through systematic use of a far infrared sauna, you can mobilize these toxins and they can be excreted through your sweat and through your urine and through your bowel. So it's a tremendous way to promote wellness and purify your body.
Sanjiv Lakhia: 11:42 If you're considering using a far infrared sauna, you should keep in mind a few things. Number one, you want to go very slow. High Tech Health, when we purchased ours, they gave us a protocol where you start with as little as five minutes at a low temperature, and over the course of a month build up your time and exposure. You can experience some initial headache and detoxification type side effects, so you don't want to rush into sauna treatment.
Sanjiv Lakhia: 12:03 Number two, you have to see very well hydrated. So when I'm in my sauna, I typically have a fairly tall glass of water, and I use electrolyte drops in the water to maintain my potassium and magnesium levels, and that's the third consideration. A lot of people who do sauna therapy forget to rehydrate and supplement with minerals that are necessary so you don't develop any mineral deficiencies.
Sanjiv Lakhia: 12:26 If you Google this, there are more exotic detoxification protocols I don't really want to get into, but one way to get the most benefit of the sauna is to do a little bit of exercise before you get in. This will increase circulation in your tissues, open up your capillaries and allow for a better effect of the sauna. So I typically do my sauna treatments after I've done a bit of cardio or some circuit training. So as I sat in my sauna this morning, I couldn't help but notice how relaxing the effect is. It really helps with stress and with pain reduction. If you get a chance to trial a sauna, even a dry sauna at the gym, please do. It can be a valuable tool in your toolbox to dealing with your back pain or other orthopedic injuries.
Sanjiv Lakhia: 13:08 Let's dive into today's topic, which is minimally invasive spine surgery. Can you define for our listeners what exactly minimally invasive spine surgery is, or as we call it, MISS?
Mark Smith: 13:18 I can tell you how I define it, and there's some confusion around what is legitimate minimally invasive spine surgery. We know there are certain structural problems in the spine that when corrected will help a patient feel better or function better, have less pain, have improved strength, those types of improvements in nerve function. So minimally invasive surgery would be one where we accomplish those structural changes, the same ones that would be accomplished with an open surgery, but do those with less trauma to the body. In other words, instead of making a six inch incision and directly visualizing all the spine structures, we make a one inch incision or a two centimeter incision and only visualize a portion of the spine that needs to be corrected. And in doing so, we cause significantly less trauma to the musculature and create less morbidity, which means damage when we do the procedure.
Mark Smith: 14:28 Now, I don't believe that all minimally invasive spine surgery is the same. So if you hear of a procedure described as a minimally invasive procedure that turns out to be minimally effective, well then to me that's not true minimally invasive spine surgery. And there's some mimickers out there and some procedures that may seem attractive because they don't seem like they carry much morbidity at all that turn out to be minimally effective, and I'd stay away from those procedures.
Sanjiv Lakhia: 15:08 Are you able to give us a little more specifics on that? If I'm a patient out there with a herniated disk and I think I need surgery, are there certain procedures that you personally would say guard against?
Mark Smith: 15:18 Sure. So a herniated disk is a piece of firm cartilage pushed out from the disk against the nerve root, and that piece of disk material needs to be removed for the pressure on the nerve to be resolved. So a laser procedure, or a heating procedure, or even some type of endoscopic decompressions don't adequately accomplish that, so there needs to be a certain amount of exposure at the time of surgery to accomplish that goal, and if that's not allowed by the procedure, then I would consider that a reasonable minimally invasive operation.
Sanjiv Lakhia: 16:05 And on this show, I really try and break it down into simple, easy to understand terms and definitions. Minimally invasive spine surgery. So if you don't make a big incision, how are you able to see what you need to see? What are kind of the tools that are utilized during the procedure?
Mark Smith: 16:21 Sure. So in every minimally invasive spine surgery, we use a live x-ray machine called fluoroscopy. So we know based on the preoperative imaging where the pathology is, and we localize that with an x-ray, and we guide our tools toward that area of pathology using the x-ray, so we have confirmation that we're in the right location and that location correlates to what we see on the MRI. And in most cases, we have specially designed instruments that we use with a camera or a microscope to visualize a small area of anatomy to make it look larger so that we can conduct the same type of technical procedural aspects to that we would in a larger open surgery.
Sanjiv Lakhia: 17:15 So it's really leveraging tools and technology to provide the surgeon with as much information they need while performing the least invasive or least damaging procedure to get that information, which is similar ... Would you say it's similar to orthopedics? How they, again, using arthroscopy to look in shoulders and then that evolved to looking in hips, and it's a similar concept for individuals to understand that in the world of spine surgery we try and do as little as we have to to accomplish the goal.
Mark Smith: 17:46 That's a great way to think about it, and minimally invasive spine surgery has followed a lot of the surgical subspecialties, general surgery, orthopedics, cardiology, so we honestly have a shorter history in spine surgery than those other specialties do.
Sanjiv Lakhia: 18:06 And you covered this a little bit earlier, the benefits, can you list those again in terms of a minimally invasive procedure versus an open procedure? Is it predominantly the benefit is in the recovery time?
Mark Smith: 18:19 Sure. There are a couple of very well-defined and proven benefits of minimally invasive surgery, and I'll just list a couple of those. There's less blood loss during surgery, there's less postoperative pain, shorter hospital stays are very common, reduced need for a blood transfusion, and probably one of the most important, particularly in spinal fusion surgery, there's a lower infection rate. Now, those of us that do these procedures commonly also feel that the adjacent segments to the segment that we operate on are placed under less stresses postoperatively after a fusion. So, that decreases the disease that may develop in an adjacent segment over the years after the surgery. Now that we think is correct, but we haven't fully proven that. Most minimally invasive spine surgeons believe it, and I tell my patients that's likely the case too. So those benefits are obviously great, but only if the surgery itself is effective. A short one hour surgery that doesn't exact the benefit that we're trying to accomplish is not better for a patient than a two hour surgery that requires a hospital stay.
Sanjiv Lakhia: 19:46 If you have a patient in the office who comes in and you're pretty convinced that they have a disk issue, and maybe some instability that's contributing to their back and leg pain, how do you as a neurosurgeon kind of process that information and make a determination about whether or not they're a candidate for a minimally invasive approach versus an open approach?
Mark Smith: 20:07 We define that in a couple of ways. The more focal the pathology is, the more likely a minimally invasive approach will work. Now, the question of instability involves some judgment. We use dynamic x-rays to look at the movement of the spine in different positions, and if there is abnormal motion on, say, flexion-extension x-rays, occasionally we are required to do stabilization as a part of the procedure, but that's always a conversation I have with the patients in front of their imaging, and we occasionally will have two options for surgery. If there's some indication that the instability is mild, then a fusion may be avoided, at least for the short term, and many patients will opt for a smaller procedure initially with close monitoring and follow up.
Mark Smith: 21:05 And I should mention, we also are very diligent about diagnosis in minimally invasive spine surgery. We're doing very focal operations typically involved in the treatment of a limited number of nerve roots. So, pain in the leg has to be very defined to one or two nerve root distributions for us to be as confident that patients are going to respond well to surgery. So I take additional time in the office, and as you know, order additional testing if there's any question regarding what the pain generator is, and even diagnostic injections occasionally to predict what the outcome of surgery will be. And when we take that extra time, we increase the specificity of our diagnosis and we're more able to predict surgical outcome for our patients.
Sanjiv Lakhia: 22:01 What Mark just described is the reason why, if you were to come to our practice with a condition in your back, that you will frequently be questioned whether or not the symptoms are going down your leg, and is it going in a specific location? We try to narrow down as close as we can the exact pain generator, which also may be a reason why if you have diffused pain, meaning pain all across your back, down both your legs, that's very hard to pinpoint based upon the day or the activity why there may be more hesitancy to have surgery performed, and more specifically minimally invasive procedure. So what he spoke to there, folks, is the ability to really hone in on the diagnosis, figure out exactly what the problem is, and if we can do that, then your odds of having successful outcomes with surgery or nonsurgical care definitely will go up.
Sanjiv Lakhia: 22:50 You mentioned this before a little bit, but cover again: standard recovery times. So people want to know, "Hey, when I get the surgery, how long am I under? And then how long before I can either get back to work and then how long if I can get back to athletic activities?"
Mark Smith: 23:03 I'll break that down into two different categories. One category would be minimally invasive diskectomy or laminectomy, and the other is minimally invasive fusion. So for diskectomy or laminectomy, patients may require some pain medication for a day or two. They're immediately mobilized after surgery. They're kept at light activity, which means reduced lifting, walking program for the first four weeks, and then they're placed in physical therapy with a return to full activity between eight and 12 weeks postoperatively, depending on their progress with physical therapy and their desired activity. I obviously assume a wrestler's going to be on a different plan than a couch potato.
Mark Smith: 23:51 Now, for a lumbar fusion, I extend that by a couple of months, so same walking program for the first four weeks. Typically a little more in the way of pain medication for the first two to four weeks, and then physical therapy lasting four to six weeks, usually finishing up by 12 weeks post-op. Full activity for a fusion can occur between three and six months, depending on what the specific activity is. Golfers, tennis players, runners, more active patients require more time. That's not necessarily to let the surgical site heal, but to strengthen the areas around the surgery. Techniques that we use to do a stabilization or fusion surgery provide significant amount of stability in the region of our operation, but that does create some stresses on the segments above and below, so we want patients to be strong in their core and flexible before obtaining their most strenuous activity.
Sanjiv Lakhia: 25:01 We're recording the podcast today in Ballantyne, which is a suburb of Charlotte, and we're in a corporate park, so we see a lot of corporate workers, bankers, people with more sedentary desk type work. For those folks who have the minimally invasive diskectomy or laminectomy, how quickly can you release some typically back to work?
Mark Smith: 25:22 A lot of patients begin to work from home right away. Some probably, against the best advice, are back to work within a week.
Sanjiv Lakhia: 25:31 Sure. Yeah.
Mark Smith: 25:33 Physicians included in that category. Usually one to two weeks for most people.
Sanjiv Lakhia: 25:39 I get a lot of golfers who come in and they want to get right back on the course within a day or two. So there is some expectation setting that has to happen, so thanks for sharing that information with the listeners.
Mark Smith: 25:49 Sure.
Sanjiv Lakhia: 25:50 Most of what we discussed today has primarily focused on the low back. Are there also minimally invasive techniques that are utilized in the cervical spine to treat pinched nerves? Ruptured disks?
Mark Smith: 26:00 There are great options. The options are slightly less in number than what we have for the lumbar spine because of the anatomy of the cervical spine. In the cervical spine, the bone surrounds the spinal cord, and the spinal cord itself cannot be manipulated. So if there's anatomic pathology that causes compression of the spinal cord or compromises the canal, or ring of bone that surrounds the spinal cord, then minimally invasive surgery may not be an option. But for the typical herniated disk with arm pain, unilateral arm pain specifically, there are great posterior cervical procedures that have been performed for many years here with great success.
Sanjiv Lakhia: 26:49 Posterior? You mean from the back?
Mark Smith: 26:51 That's correct.
Sanjiv Lakhia: 26:52 When you do the minimally invasive techniques, are there any downsides? Does it affect the risk of a disk re-herniating? Does it create more scar tissue? Or is all of that just better because you're doing less damage to the tissue?
Mark Smith: 27:05 So if a minimally invasive surgery is done correctly, then you're accomplishing the same structural benefit that you would in a large or open surgery. So the risks in general should be the same. Now, the more technically demanding minimally invasive procedures have to be learned and should be learned in a fellowship or a program that has a lot of volume, because there is a learning curve to the procedures, but an experienced minimally invasive surgeon's risk profile should be no different than a typical open surgery. I did notice earlier in my career, because there is very little postoperative pain from the surgery itself, that patients sometimes are too active after surgery, and increased activity, increased stress on the spine can create a scenario where a disk can re-herniate or a patient can injure the site of surgery. So I'm diligent with patients about their activity postoperatively so they heal appropriately.
Sanjiv Lakhia: 28:18 You touched earlier on laser surgery, mentioned that briefly. I got to tell you, it's probably the number one question I get in the office and have for years for various reasons, and I don't really necessarily want to get into the history of the Laser Surgery Institute and all that that surrounds it, but I would like to get your opinion just on, are lasers utilized as a standard of care within the field of neurosurgery? And if so, in what capacity? And if not, then why not?
Mark Smith: 28:52 The short answer is no. Lasers are not used, and I may be one of the only neurosurgeons around who has actually seen a laser used in surgery. We actually, in residency, occasionally use the laser to resect certain types of spinal tumors. So surgeries generate heat, they cauterize tissue, or shrink it, or stop bleeding. That's what a laser does, and that is useful in some tumor surgeries, or was years ago, and now we have better techniques to use. So there really is no laser that we can point at the disk and create any kind of improvement for a patient. It turns out just to be really a catchy term.
Sanjiv Lakhia: 29:41 But I think it speaks to patients' desire to have a surgery that is less invasive with quick recovery times. Would you say it's a fair statement that the standard minimally invasive spine techniques that are offered now can really accomplish those things that patients are looking for?
Mark Smith: 29:59 They most certainly can, and patients should know, when you see a surgeon or see me, I can give you my experience. I'm going to design the surgery, if it's appropriate, that'll take care of the problem and make a patient feel better. And the last thing that I want to do is operate on a condition that I know is unlikely to improve or to stretch the indications for surgery beyond what could be effective.
Sanjiv Lakhia: 30:30 That's fantastic. Okay. Moving on to our last couple of questions. Again, we're here with Dr. Mark Smith. I really appreciate his time, and he's helping educate us on minimally invasive spine surgery. Are there insurance hurdles or things that have to be done by the patient before we can offer them minimally invasive spine techniques?
Mark Smith: 30:51 So most diskectomies or laminectomies are typically easy to be approved by insurance companies, and particularly in our practice because we have a focus on conservative care, so patients have typically received appropriate nonoperative therapy by the time that they're evaluated by the surgeon. Now, minimally invasive surgery as we define it is not controversial, so we're not doing procedures that are not well accepted or outside the box, so those are the types of things that insurance companies can be less enthusiastic about.
Mark Smith: 31:32 Now, in regard to fusion, there is some additional documentation that's required, because fusion surgery is more expensive, and for an insurance company they require more justification to perform the procedure. In our indications, in this practice, there's typically not an issue with having approval by an insurance company for that type of procedure, but it may require additional documentation.
Mark Smith: 32:04 Patients do have increased responsibility when it comes to fusion surgery. There is typically some rigidity about the amount of conservative therapy that's required. Patients do need to stop smoking if they smoke, and weight loss may be required as well. But since we operate well within the standard of care, if we deem a patient a surgical candidate, they're typically approved, even though it may take some additional work.
Sanjiv Lakhia: 32:32 And by the way, all the things he just mentioned, the weight loss, smoking cessation, these are going to help you recover from surgery, they're going to decrease your risk of infection, and really just improve your outcome. So I think there's reasons why those are emphasized when they're offering you surgery.
Sanjiv Lakhia: 32:50 And moving on to our last question, Mark, are there any new technologies on the horizon in the field of minimally invasive spine surgery that gets you excited?
Mark Smith: 32:58 Well, I think we're in kind of the golden age of spine surgery at this point. I trained in Memphis, and one of my mentors really sparked the modern minimally invasive spine revolution, so I was lucky enough to be on the front end of that, and that's certainly been to my advantage in practice. Almost any surgical approach you can imagine has a minimally invasive option at this point, and as we grow in our understanding of what pathologies are best treated with certain techniques, we're going to continue to see better tools developed by spinal instrumentation companies, better approaches developed by our general surgery colleagues, and further improvement in morbidity that we create for our patients. Now, honestly, the holy grail to spinal issues would be a biological solution such that we could prevent the degenerative change that occurs in the disk, and while there are always studies ongoing about that, we're not quite on the cusp of figuring that one out yet.
Sanjiv Lakhia: 34:18 And on future episodes, I'm lining up some people where we can have a discussion about the status of stem cells and PRP, and the new biologic agents that are out there from a nonsurgical perspective. Dr. Cheadle mentioned on our previous podcast robotics. Do robotics fall under the umbrella of minimally invasive spine surgery?
Mark Smith: 34:41 They do. A robot can be used in an open spine operation or a minimally invasive operation. The robot follows a navigation plan that you create based on the patient's unique anatomy, and we benefit from specialized directional devices used in the operating room, and even interoperative CT scan. So our techniques have evolved because of those, and radiation exposure to both the patient and the surgeon has been diminished, but they still don't replace experience and skill at this point. What we see on the computer screen has to match with what our anticipation of the anatomy is and our surgical feel for the bony anatomy. So there are a significant number of technological advances, but they have to be married to a skillset as well.
Sanjiv Lakhia: 35:44 And Mark, I know there's one more point that you wanted to make to our listeners with regards to their decision making process for minimally invasive spine surgery or spine surgery of any type.
Mark Smith: 35:55 That's right. I think it is most beneficial for patients to go to a surgeon or group that offers all techniques, such that there is no bias instilled into the visit based on the surgeon's capabilities or surgeon's partner's capabilities or technique. So by having a comprehensive set of procedures available, we're able to make the best choice for the patient without any type of bias. My mentor described minimally invasive spinal instrumentation as ship in a bottle surgery, and as I was a kid and thought back to seeing pieces of art where entire ships were constructed inside a glass bottle, it really made a lot of sense and connected with me. So we're creating an instrumentation in a patient's spine without creating significant damage in the skin, and without essentially breaking the bottle that is the structure of the spine.
Sanjiv Lakhia: 37:09 That's a terrific explanation. I appreciate you sharing that. Well, there you have it folks. You're not going to find a better breakdown with regards to minimally invasive spine surgery, the ins and outs, than what Dr. Mark Smith just provided for you today. He covered quite a bit, helped define it for us, went through the indications and the risks, discussed recovery times. He discussed even downsides and how they decide between open and less invasive procedures. So Mark, I really appreciate your time today. I think this is going to be very informative to the listeners, to our patients, and clearing up some confusion that's out there with regards to this topic. So once again, thank you so much for taking the time today.
Mark Smith: 37:48 You're welcome. I enjoyed being here.
Outro: 37:50 Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available carolinaneurosurgery.com.
