Episode 33 - In’s and Out’s of Spinal Fusions with Dr. Hunter Dyer
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Episode Summary
The general public’s understanding of spinal fusion often starts with a misconception.
When Dr. Hunter Dyer talks to people about lumbar fusion, many think that it’s the screws doctors place that are the fusion. But that’s not true — the hardware just holds the spine in alignment until the vertebrae or spinal elements grow back together.
As an expert in spinal fusions, Dr. Dyer is familiar with what people get wrong or just don’t understand about caring for their spine and fixing spinal issues. It’s a complicated field of medicine and, as such, patients considering surgery like a fusion should consult with an expert first.
For example, Dr. Dyer says that most patients with back pain don’t actually need surgery. Rather, alternative care like physical therapy is often a better starting point before committing to the sometimes-extensive recovery from a fusion procedure.
In addition, there are myriad risk factors to consider: Does the patient smoke? What’s their surgical history? How old are they? What’s their body type? All these things and more, Dr. Dyer says, can influence whether a patient is a good candidate for a spinal fusion.
On this episode of Back Talk Doc, Dr. Dyer explains all things spinal fusion with host Dr. Sanjiv Lakhia.
Featured Guest
Name: Dr. Hunter Dyer
What he does: Dr. Dyer is an expert in degenerative spine disease, endoscopic spine surgery, minimally invasive spine surgery, skull base surgery, spinal fusion, transsphenoidal surgery and vascular neurosurgery. He is the President at Carolina Neurosurgery & Spine Associates.
Company: Carolina Neurosurgery & Spine Associates
Words of wisdom: “The key to any great job, or being good at what you do, is I absolutely love what I do. I wake up every single day excited to see what I've got for the day and see if I can help people surgically, to see if I can help people in the clinic. And that's why we love being physicians and we love being in health care, because it's just so rewarding.”
Connect: LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Most spinal issues probably don’t need surgery. Even as a surgeon, most patients Dr. Dyer sees can address their issues with conservative care — physical therapy, spinal traction, or injections. “The only people that we need to consider for spinal fusion are typically those that have problems where they require so much bone removal that they require stabilization of the spine,” he says.
Smoking is a major risk factor for spinal issues. It can affect people with problems in either the neck or back. “We typically do not like to even consider spinal fusion if somebody is using tobacco,” Dr. Dyer says. “If they've used it in the past, it's likely that they get degeneration of the disk and that can lead to accelerated adjacent-level problems.”
The direction of spinal surgery can influence the healing process. Dr. Dyer explains that when a surgeon uses a lateral approach, patients don’t often experience a lot of pain. When the best course of action involves the posterior or anterior approach, patients can experience more pain after surgery. “In general, there's more pain with the posterior approach, but it's still the most common way because it does provide that direct view of the nerves,” he notes.
Spinal fusion techniques are advancing rapidly — which is good for patients. In the past five years, technology has advanced so that surgeons can be more precise with placing screws, thanks to MRI and CT images. In addition, robotic tools have made surgery much safer and much easier to heal from. “For many people, it’s just a better thing all around,” Dr. Dyer says.
Episode Insights
[00:00] Mobile-based solutions for clinical practice: Check out our sponsor, QxMD, mobile solutions for driving evidence-based medicine in clinical practice.
[01:45] Introducing the physician: Dr. E. Hunter Dyer is a specialist in degenerative spine disease and endoscopic spine surgery, among other things.
[03:50] Neurosurgery isn’t just for the brain: The reality, Dr. Dyer says, is that spinal issues make up the majority of neurosurgeons’ caseloads.
[05:50] Conservative care can help most spinal issues: Care options like physical therapy or injections are often the first steps in recovery before exploring spinal fusion.
[8:20] What is lumbar fusion?: It’s not actually referring to the hardware. “Fusion is actually the growth between or around the spinal elements, whether it's the vertebrae growing together, or whether it's the spinal elements in the back part of the spine that grow together,” Dr. Dyer explains.
[10:40] Two types of spinal instability: One is in patients who haven’t had any procedures and have their vertebrae moving due to degeneration of spinal joints; the other is found in someone who has had excess bone removed, creating an unstable spine where doctors must secure spinal segments.
[13:00] Changes for lower back care: Dr. Dyer says spinal fusions for lower back pain are much less common than they were a decade ago.
[15:30] Differences in lumbar fusion acronyms: Dr. Dyer explains what ALIF, XLIF and other types of fusions actually mean.
[18:40] Recovery times vary: Dr. Dyer explains how and why the healing will differ depending on whether a surgeon uses an anterior, lateral, or posterior approach.
[20:40] Complexities of evaluating spinal surgery: A myriad factors within a patient can influence what types of treatment are best.
[23:44] Breaking down recovery restrictions: Post-surgery recovery varies from person to person but often can last several weeks at minimum.
[27:15] Benefits of physical therapy: Most spinal fusion patients find that physical therapy helps at a certain point in their recovery.
[28:26] On adjacent-level disk disease: Dr. Dyer explains the importance of identifying the exact problem in the patient, common post-spinal fusion issues and risk factors.
[32:27] Outlook for future surgery: There is a possibility that patients who have lumbar fusion could require an extension or further surgery down the road. Dr. Dyer says while it’s not common and it is a “complete game changer” for some, doctors should educate patients about possibilities down the road.
[34:45] Are spinal fusion surgeries overdone?: Dr. Dyer discusses why some in the medical community have the perception that not all spinal fusions are necessary and shares current insights on when it makes sense to skip the procedure.
[37:06] Looking ahead: Robotic tools, minimally invasive procedures, and new imaging technology are making for quicker-healing and less-painful procedures. “There also are incredible advances in what we call navigation,” he says, noting that navigation enables doctors to attach instruments to the imaging study.
[40:43] Final thoughts: “I'm not the best example of somebody who is an extremely regular exercise person, but I stay on the go and I think my metabolism stays at a high rate, which helps,” he says reflecting on what has helped his success. “I lean on having great family support. I've got a great wife and kids. And also the key to any great job [is] I absolutely love what I do.”
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Reduce Back Pain and Improve Posture with Active Sitting.
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
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.
The general public’s understanding of spinal fusion often starts with a misconception.
When Dr. Hunter Dyer talks to people about lumbar fusion, many think that it’s the screws doctors place that are the fusion. But that’s not true — the hardware just holds the spine in alignment until the vertebrae or spinal elements grow back together.
As an expert in spinal fusions, Dr. Dyer is familiar with what people get wrong or just don’t understand about caring for their spine and fixing spinal issues. It’s a complicated field of medicine and, as such, patients considering surgery like a fusion should consult with an expert first.
For example, Dr. Dyer says that most patients with back pain don’t actually need surgery. Rather, alternative care like physical therapy is often a better starting point before committing to the sometimes-extensive recovery from a fusion procedure.
In addition, there are myriad risk factors to consider: Does the patient smoke? What’s their surgical history? How old are they? What’s their body type? All these things and more, Dr. Dyer says, can influence whether a patient is a good candidate for a spinal fusion.
On this episode of Back Talk Doc, Dr. Dyer explains all things spinal fusion with host Dr. Sanjiv Lakhia.
Featured Guest
Name: Dr. Hunter Dyer
What he does: Dr. Dyer is an expert in degenerative spine disease, endoscopic spine surgery, minimally invasive spine surgery, skull base surgery, spinal fusion, transsphenoidal surgery and vascular neurosurgery. He is the President at Carolina Neurosurgery & Spine Associates.
Company: Carolina Neurosurgery & Spine Associates
Words of wisdom: “The key to any great job, or being good at what you do, is I absolutely love what I do. I wake up every single day excited to see what I've got for the day and see if I can help people surgically, to see if I can help people in the clinic. And that's why we love being physicians and we love being in health care, because it's just so rewarding.”
Connect: LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Most spinal issues probably don’t need surgery. Even as a surgeon, most patients Dr. Dyer sees can address their issues with conservative care — physical therapy, spinal traction, or injections. “The only people that we need to consider for spinal fusion are typically those that have problems where they require so much bone removal that they require stabilization of the spine,” he says.
Smoking is a major risk factor for spinal issues. It can affect people with problems in either the neck or back. “We typically do not like to even consider spinal fusion if somebody is using tobacco,” Dr. Dyer says. “If they've used it in the past, it's likely that they get degeneration of the disk and that can lead to accelerated adjacent-level problems.”
The direction of spinal surgery can influence the healing process. Dr. Dyer explains that when a surgeon uses a lateral approach, patients don’t often experience a lot of pain. When the best course of action involves the posterior or anterior approach, patients can experience more pain after surgery. “In general, there's more pain with the posterior approach, but it's still the most common way because it does provide that direct view of the nerves,” he notes.
Spinal fusion techniques are advancing rapidly — which is good for patients. In the past five years, technology has advanced so that surgeons can be more precise with placing screws, thanks to MRI and CT images. In addition, robotic tools have made surgery much safer and much easier to heal from. “For many people, it’s just a better thing all around,” Dr. Dyer says.
Episode Insights
[00:00] Mobile-based solutions for clinical practice: Check out our sponsor, QxMD, mobile solutions for driving evidence-based medicine in clinical practice.
[01:45] Introducing the physician: Dr. E. Hunter Dyer is a specialist in degenerative spine disease and endoscopic spine surgery, among other things.
[03:50] Neurosurgery isn’t just for the brain: The reality, Dr. Dyer says, is that spinal issues make up the majority of neurosurgeons’ caseloads.
[05:50] Conservative care can help most spinal issues: Care options like physical therapy or injections are often the first steps in recovery before exploring spinal fusion.
[8:20] What is lumbar fusion?: It’s not actually referring to the hardware. “Fusion is actually the growth between or around the spinal elements, whether it's the vertebrae growing together, or whether it's the spinal elements in the back part of the spine that grow together,” Dr. Dyer explains.
[10:40] Two types of spinal instability: One is in patients who haven’t had any procedures and have their vertebrae moving due to degeneration of spinal joints; the other is found in someone who has had excess bone removed, creating an unstable spine where doctors must secure spinal segments.
[13:00] Changes for lower back care: Dr. Dyer says spinal fusions for lower back pain are much less common than they were a decade ago.
[15:30] Differences in lumbar fusion acronyms: Dr. Dyer explains what ALIF, XLIF and other types of fusions actually mean.
[18:40] Recovery times vary: Dr. Dyer explains how and why the healing will differ depending on whether a surgeon uses an anterior, lateral, or posterior approach.
[20:40] Complexities of evaluating spinal surgery: A myriad factors within a patient can influence what types of treatment are best.
[23:44] Breaking down recovery restrictions: Post-surgery recovery varies from person to person but often can last several weeks at minimum.
[27:15] Benefits of physical therapy: Most spinal fusion patients find that physical therapy helps at a certain point in their recovery.
[28:26] On adjacent-level disk disease: Dr. Dyer explains the importance of identifying the exact problem in the patient, common post-spinal fusion issues and risk factors.
[32:27] Outlook for future surgery: There is a possibility that patients who have lumbar fusion could require an extension or further surgery down the road. Dr. Dyer says while it’s not common and it is a “complete game changer” for some, doctors should educate patients about possibilities down the road.
[34:45] Are spinal fusion surgeries overdone?: Dr. Dyer discusses why some in the medical community have the perception that not all spinal fusions are necessary and shares current insights on when it makes sense to skip the procedure.
[37:06] Looking ahead: Robotic tools, minimally invasive procedures, and new imaging technology are making for quicker-healing and less-painful procedures. “There also are incredible advances in what we call navigation,” he says, noting that navigation enables doctors to attach instruments to the imaging study.
[40:43] Final thoughts: “I'm not the best example of somebody who is an extremely regular exercise person, but I stay on the go and I think my metabolism stays at a high rate, which helps,” he says reflecting on what has helped his success. “I lean on having great family support. I've got a great wife and kids. And also the key to any great job [is] I absolutely love what I do.”
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Reduce Back Pain and Improve Posture with Active Sitting.
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
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: 00:00
This podcast is sponsored by our partner, QXMD. QXMD builds mobile solutions that drive evidence based medicine in clinical practice. Check out READ for easy access to research personalized for you, and CALCULATE for over 500 easy to use decision support tools. Try them today at QXMD.com/apps. Again, that is QXMD.com/apps.
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: 01:04
As a board certified physiatrist I do feel like it's may day-to-day job to try and help patients to avoid surgery, particularly spine surgery, as that's the majority of my practice. But obviously not everyone can avoid surgery and on Back Talk Doc we've had several great interviews dealing with the idea of spine surgery.
If you haven't had a chance, please go back and check out my episode where I interview Dr. Mark Smith about minimally invasive spinal surgical techniques, and also listen to the interview that I do with Dr. Joe Cheatle where we talked about lumbar stenosis, and he reviewed definitely some surgical techniques as well.
But today I'm delighted to jump into the topic of lumbar spinal fusion surgery and I want to welcome my guest Dr. Hunter Dyer to the show. Hunter welcome to the show.
Hunter Dyer: 01:57
Thank you. Good to be here.
Sanjiv Lakhia: 01:58
Now Hunter is the president of our group at Carolina Neurosurgery and Spine Associates, and he's had a long distinguished career and continues to rack up accolades. His specialty interests are degenerative spine disease, endoscopic spine surgery, minimally invasive spine surgery. He also does skull based surgery, spinal fusions, as well as many other things.
Educationally, he went to medical school at the University of Mississippi. He did residency and internship at the University of Texas South Western medical center, Dallas, and he did a fellowship in pituitary and skull based surgery, and did some training in France.
So, he is one of the most distinguished neurosurgeons in the Charlotte area, if not nationally, and he has graciously volunteered his time to help educate us today on the topic of spinal fusion surgery. But before we dive into that, for those in the community who are listening who don't know you all that well, feel free to elaborate on your background and maybe share on your path to the field of neurosurgery.
Hunter Dyer: 03:01
Absolutely. Happy to.
So, as Sanjiv said, I did my medical school in Mississippi and then went to Texas for my training. I was fortunate in that my training there, I had one of my current partners, Dr. Tim Adamson, who was in residency with me there, and so he talked me into looking at this practice in Charlotte, and fortunately for me it worked out great. We've enjoyed being in Charlotte over the last 26 years and we've been able to build a fantastic practice and it's just been a great place to work and we enjoy it to this day.
Sanjiv Lakhia: 03:39
Now in your day to day practice what percent of patients that you see, would you estimate, end up needing a lumbar fusion surgery?
Hunter Dyer: 03:49
Right. Well, I'd like to say first, when people think of neurosurgeons we're known for our cranial treatment, whether it's head injury, other problems of the brain, and for being a brain surgeon. But in reality neurosurgeons spend at least 70%, sometimes up to 80% or 85%, of their time taking care of spinal problems. So, when I see office twice a week, the majority of my patients have problems of the cervical or lumbar spine primarily, and that is across the board the way it is for all neurosurgeons around the country. Spinal issues are just much more common than cranial issues. Certainly when we are on call at night we see a lot of cranial problems that come through the hospital, and we do see some in our day to day practice in the office, but spinal issues are extremely common and spinal fusion is one of those things that we see really on a daily basis in the office setting.
Sanjiv Lakhia: 04:46
Yes, for sure. It's the whole basis for the podcast. The burden of spine care in this country is just enormous and we've outlined on previous episodes a lot of the non-surgical approaches that a fantastic podcast with Dr. Vemuri where we talked about the surgical spine. I did one with Dr. Otis on the thoracic spine and I've done one with Dr. Sumich on lumbar injections. But I will tell you in terms of interest, there is no shortage of interest in the public when it comes to spine surgery and in particular, patients that I encounter on a day to day basis, or even friends or family, they want to know just a couple of things. They want to know what's new and how quick can I recover. I think the answer to those questions, it will be helpful to the listeners if you could walk us down the path in a typical daily [inaudible 00:05:41]. Someone comes in to see you. How are you evaluating people from a surgical perspective before we even get to the idea of discussing lumbar fusion?
Hunter Dyer: 05:50
Sure. Well first of all, even for a surgeon, the majority of spinal issues that we see are things that can be dealt with, with conservative care. So everybody we see, again even as a surgeon we're saying, have you done physical therapy, have you done traction, have you done injections, how long has it been that you've had symptoms, have you had any previous procedures? So part of the history is making sure that they even need to begin a discussion about surgery or not.
Now, as far as a fusion goes, especially in the lumbar spine, there are many, many people that have symptoms that pertain to just a single nerve root in the lower back. And by that I'm talking about pressure on either one of the nerve roots that forms the sciatic nerve, most people are familiar with that type of pain that goes down from the lower back to the buttock and then all the way down the leg, typically to the foot or the ankle. Some people have pressure on the nerve root in their lower back that affects the femoral nerve, that goes again down the buttock, typically down the front of the thigh, sometimes past the knee, even down along the shin.
So, when people have that type of a pinched nerve symptom, the majority of people are able to try conservative care first. If that doesn't work there are many, many minimally invasive procedures where we can isolate a single nerve that's pinched, and surgically decompress that nerve.
The only people that we need to consider for spinal fusion are typically those that have problems where they require so much bone removal that they require stabilization of the spine. So, spinal fusion involves trying to get vertebrae in the spinal elements to grow together, to grow bone to connect a segment, or two, of the spine.
So we try to isolate first of all, have they done everything they can, short of surgery? Can they be evaluated for minimum invasive surgery, and then if they cannot, is it something that can be considered for spinal fusion?
Sanjiv Lakhia: 08:03
One thing I would say is, let's walk it back just a touch, and my audience is a mixture of people in the public who love to listen to the podcasts, also clinicians, but can you give us a basic definition of what fusion means. When you say lumbar fusion, help people understand what exactly that term implies.
Hunter Dyer: 08:23
Right. So when we tell people, or talk to people, about lumbar fusion, often there's a misperception that if you speak about lumbar fusion, you're talking about putting in hardware in the back, in the spine. If you put a hardware in is that actually the fusion? And that's where the misperception usually falls. People think that if you are getting screws and two connecting rods on each side, that's fusing the spine. In fact what the hardware does, is just hold the spine in proper alignment until bony growth is achieved. So the fusion is actually the growth between, or around, the spinal elements, whether it's the vertebrae growing together, or whether it's the spinal elements in the back part of the spine that grow together.
Typically, people that have spinal instrumentation put in, have bone graft material put in also. The bone graft material can be, it's usually bone that we take out of the spine and reintroduce to the spine to try to get it to fuse, or it includes other bone products that encourage bone growth.
So I try to clarify that with patients quickly because it is such a common notion that patients have that when they get spinal instrument put in that that actually is the fusion, but the spinal fusion is actually the growth of bone to connect that part of the spine. To make it no longer mobile.
Sanjiv Lakhia: 09:51
That's an excellent clarification, thank you for that.
And then I want to respond to what you said earlier. What I like to tell patients is that with surgery, if it gets to the point where they have to remove enough bone, it can create an environment that's slightly unstable. Something akin to, if you take too many bricks out of a foundation of a home, it can make it unsteady. So what you are doing there, if I am hearing correctly, is the hardware comes into play when you've made a medical assessment of the situation into freeing up a nerve or two, is going to require enough of an intervention that it could create almost an unstable environment, and that's where you have to then insert the hardware. Is that reasonably accurate?
Hunter Dyer: 10:39
That's exactly right. So we have two different types of instability. One in which a patient who's not had any procedures, and has not had any intervention, comes in and we can do x-rays of the spine, with a person leaning forward and backwards, and we see instability where the spinal vertebrae are actually moving. And that results from degeneration of the joints in the spine that connect one vertebrae to the next. That's one type of instability.
The other type you mention is that, if we actually have to remove excessive bone to free up the nerves, then we are basically creating an unstable situation in which we have to secure the spinal segments.
Now, I'm always quick to tell my patients, one thing that's complicated about the spine is that every vertebral segment in the spine has a joint that can exit to the next. Some people think, well gosh, this must be an analogous to get my knee replaced, or my hip replaced. Well those are single joints that can actually be replaced, and can work in an analogous way to the way they did prior to replacement.
With the spine we are usually addressing one or more segments of the spine but they're still many mobile segments above and below. So in other words, if we have to do a spinal fusion, it might be between lumbar segments three and four, and that makes that level no longer a moveable segment, but there's still motion in all the segments above and below.
So, another common misperception is that if you have a spinal fusion, that you look different, or that you're stiff looking, or that you can't lean over and tie your shoes, and of course that's certainly not the case. There are people that have larger fusion procedures for problems like scoliosis where they could have a much longer segment of their spine that's fused, but in the vast majority of people, you're talking about one or two spinal segments.
Sanjiv Lakhia: 12:40
You mentioned before, the idea of someone coming in with a trapped nerve root which would certainly cause a lot of pain going down the leg. Do you consider low back pain... are there situations where low back, without the leg symptoms, is an indication possibly for lumbar fusion surgery?
Hunter Dyer: 13:00
The number of times that we do spinal fusion surgery, just for lower back pain is certainly much less than it was, say 10 or 15 years ago. The reasons for that are, we know that with the majority of the spinal surgery we do is essentially for leg pain because of a pinched nerve. Now when we were talking about spinal fusion surgery, even though we're putting in instrumentation and getting the spine to remain stable by having the bone grow there, the first part of almost every spinal fusion surgery involves decompressing the nerves and making sure the nerve pain is resolved. So, I tell people when they're having a spinal fusion that I spend the first 30 minutes to an hour making sure the nerves are free, taking off the amount of bone I'd need to resolve that part of the pain, and then the second part of the operation, putting in the instrumentation and completing the spinal fusion.
But the number of people that we know from research, and from years of data, that we have to be extremely selective about recommending spinal fusion if somebody only has back pain. And the reasons for that are that back pain can be multi-factorial. We know that people get arthritis as they get older. It's very hard to look at an imaging study and say well I'm going to do a spinal fusion at L3-4 because I think most of your back pain is coming from that. It's hard to localize because people that are in the age groups that typically would have a spinal fusion, may have arthritis at multiple levels.
We certainly don't want to offer surgery when we can't be reasonably sure that we're significantly going to improve the pain, or improve the problem.
Sanjiv Lakhia: 14:48
That's a great clarification. I also liked your comparison to orthopedic total joint surgery. It's just a different beast, there's different physics involved, different degrees of freedom and motion, so that's a good take on point if you're listening. It's really not akin to...we don't call it spine replacement surgery, like you call it hip replacement, or knee replacement surgery. So there's definitely a lot more involved to it.
Now, let's get into a little bit, there's almost an alphabet soup of acronyms for lumbar fusions the ALIF, TLIF, BLIF. Can you walk people through the different approaches to fusion and maybe some of those indications and what sets them apart?
Hunter Dyer: 15:33
Sure. It's not as easy to do on an audio broadcast, but I'll try to explain the different approaches that we consider for spinal fusion. The spine can be approached from the front, the lumbar spine specifically. That can be done through a trans-abdominal route, so the front of the vertebrae are actually at the back of the abdominal cavity, so spinal fusion for lumbar segments for L3-4, L4-5, and that's what we call an ALIF, the A being anterior, LIF being lumbar interbody fusions, so we can go in through the front. We can take out the spinal disk between two vertebrae, we can place an implant such as a cage between them and typically a plate on the front.
It's a very good way to have a spinal fusion that provides what we call an indirect decompression of the nerves, and by that when go from the front, we're not directly looking at the nerves, but if we take a very narrow disk space and open it up, we do create more space for nerves and that typically will relieve nerve pain.
So that's one type of spinal fusion. We also do a lateral spinal fusion which is done directly from the patient's side, right below the rib cage. This is usually done in the upper and mid-lumbar spine from about lumbar 1-2, down to 2-3, 3-4, sometimes 4-5. That is a way that we can also go into the disk space, we can put a large cage across the disk space and that provides, again, that indirect decompression where we are opening up the disk space, essentially jacking it up, where it's taller, and that provides freedom for the nerves coming out of the spine.
So both the ALIF and the, we call it an XLIF, which is a lateral approach, those are both commonly used. The most common procedure, however, is done from the back and that is when we go in and we have direct view of the spinal nerves because we are operating from the posterior approach we can see the spinal canal, we an actually follow each of the nerve roots out as they go below the pedicles, which are the prominent pieces of bone that connect the front and the back part of the spine. We decompress the nerves and then we can place screws into the pedicle which then go into the vertebrae. So those are called the pedicle screws and then we connect those with short rod segments. So those are called posterior lumbar interbody fusions, typically because we go in from a posterior approach, we place those cages in the disk space. So each of the fusions that I describe usually involve placement of interbody or cages in the disk space. Interbody referring to between the vertebral bodies.
That's probably the most common form of a fusion done in the United States at this point. And again you can do an interbody fusion from an anterior, from a lateral side approach, or from the posterior approach.
Sanjiv Lakhia: 18:37
That leads me into my next question. Do the recovery times, the healing times, differ based upon if you come from the front, the side or the back?
Hunter Dyer: 18:49
They do vary somewhat. I would say that the posterior approach, because we have to separate the muscles of the spine typically to get the materials in there, and get the nerves freed up, that muscle pain is probably more when we do it from a posterior approach. From a lateral approach there's not a lot of pain. From the anterior approach there's some pain going through the abdominal cavity and we typically do that in combination with a vascular surgeon because of the blood vessels that are in front of the spine.
So each of these approaches has its advantages and disadvantages. Sometimes people even have a combination of approaches. If they have to have a spinal fusion and they have a curvature of their spine sometimes there's an advantage to going either from the front and the back, or the side and the back. And those are a little bit larger type procedures, but those have very specific indications. It can be quite helpful for the right problem. But in general there's more pain with the posterior approach, but it's still the most common way because it does provide that direct view of the nerves. If people have extreme pressure on the nerves and they've got either disk rupture, or they've got cyst formation pinching the nerves, we really want to see those nerves directly and so we choose a posterior approach when we have to deal with that.
Sanjiv Lakhia: 20:12
Actually I do get questions from patients about, if I refer to one of my colleagues, does that surgeon do this approach, and I think if you're listening to Dr. Dyer break this down, what's clear to me is, it is a complex decision and you have to have someone who certainly has expertise in it and sounds this is a case by case scenario versus making a blanket statement that one approach is necessarily better than the other.
Hunter Dyer: 20:39
It really is. You really look at a patient's problem and there's so many different factors. Some of the factors that we are concerned about are, what is the body habitus, is the patient thin, is the patient heavy? And number two, has the patient had previous surgical treatment? If there's a lot of scar tissue from a previous approach, sometimes that can make us go from a different direction.
Scoliosis is important, so we frequently get scoliosis x-rays to make sure patients don't need something different, because if you get x-rays to look for curvature in the spine, sometimes that can change the approach that we make.
The other factor, of course, is what I talked about with the pinched nerves. If you know you can go from the front or the side and get that indirect decompression of the nerves, but is indirect compression enough. Do we need to go from posterior approach so that we can directly look at the nerves and make sure they're freed up. If we do a great spinal fusion surgery and the x-rays look wonderful and we do not get that nerve decompressed, we are not going to have a patient that has the type improvement that we want. And I can tell you that after doing this for 25 years, we have no other goal than getting a patient better as it is absolutely terrible when a patient has to go through a procedure like that, that causes pain, and they're not enough improved.
So I only get satisfaction, I think everybody would say this, when a patient achieves both a really graphic improvement in the x-rays, but most importantly in their symptomatology. If they come into my office with back pain, and leg pain that's refractory to conservative measures I want to offer them a procedure that's going to make them better. Not just the x-rays, but how they are symptomatically.
Sanjiv Lakhia: 22:28
Yes, that's great. You almost start echoing when I interviewed Mark Smith. He basically made a comment that minimally invasive is great, if it works, and that's what they need, but you're not doing anyone a favor by basically under operating, so to speak. So the primary goal here, to emphasize, is clinical improvement and these are different cervical techniques and tools we have available, that he felt like his job, as you just basically articulated, is to keep his eye on the ball and help the patient get better and use what's most appropriate.
I talk with patients about that, where I mention I want refer them onto surgery and they're like, well I don't want to have anything done major, and I say, well no one wants to, but at the end of the day, the deal breaker is living a life of disability, poor function and chronic pain. That's the deal breaker to me. So, I'm glad you articulated it in that way. I think that's a lens we should be looking at these problems through.
Now, someones come to you, you've [inaudible 00:23:29] down, let's say a one level fusion, let's say between L4 and L5, people want to know, how long am I out. What's your talking points for the recovery piece, are we talking three to six months, lifting restrictions. Break that down for us.
Hunter Dyer: 23:44
Right. I would say with the standard posterior approach I usually tell people that they can expect muscle type pain anywhere from 10 days to two weeks, typically. Now, those people are obviously not in a hospital setting for that period of time, so they usually go home with some medication and with muscle relaxers. We do have them ambulating, even the first day after surgery, so if they have their surgery as an inpatient in the hospital, they're usually getting up the next day with physical therapy.
I did two lumbar fusions today and I told both of them they would be up either later today, or in the morning. It's very important for them to get up moving quickly. The muscle pain is treated with medication. It certainly is somewhat worse right after surgery than what you experienced before, so I'm careful to make sure my patients know that in the first few days, or the first week, they shouldn't be terribly alarmed that they have more pain really than they did before. Maybe not the nerve pain, hopefully, but they've got pain localized to the back muscles and to the back, and that is simply post-operative pain. So typically that gets better.
I tell people that they can expect to be, really at three to four weeks, to recognize that they're much better than they were before surgery, and to expect to really feel like that they're over the surgery as far as energy level, getting up and around, not having that type of pain that they had before, at the two month period.
Sanjiv Lakhia: 25:15
Fantastic.
Hunter Dyer: 25:16
I also tell people that as far as the spinal fusion... it depends on the age. Spinal fusion we talked about growing bone in the spine around the area that's operated and that depends entirely on your bone metabolism, which is variable in everybody. If we have to do a spinal fusion on somebody that's very young, in their 20s or 30s, which would be unusual, they would likely form a fusion very quickly, possibly in 30 to 45 days. If we do it in somebody in their 40s or 50s, it's a little bit longer. If we have to do spinal fusion in somebody that has marginal bone metabolism, or doesn't grow bone as well, perhaps in their perimenopausal age, or even older, then we're looking at following x-rays sometimes for six months or even a year to make sure that we achieve adequate bone healing.
Sanjiv Lakhia: 26:06
This is where the idea of healthy lifestyle comes in to play, and I discuss with patients all the time that it's so important to eat well, get adequate nutrition, weight bearing exercise, and even if those things don't fix your back pain, let's say you do end up down the road needing surgery and potentially a fusion, what you just outlined there, healthy bone metabolism that is largely driven by the food we eat, the exercise, not smoking and things like that, so that's why I like to talk about the lifestyle piece on this show quite a bit because I see it play out day-to day.
So now let's say people have done well, they're about one to two months out. Do you typically recommend physical therapy, or is that case by case?
Hunter Dyer: 26:53
I would say the majority of patients that have spinal fusion, regardless of the approach, they do benefit from physical therapy. We do it in the hospital setting while they're there. Typically let the wound heal and let them get a little bit over the muscle soreness before we put them into more aggressive therapy, but I think it allows them to progress at a faster rate. I think it does help improvement after surgery.
Surgeons and physiatrists at the most part don't know all of the exercises, the muscle conditioning, the things that should tell patients as they're recovering, so patients like to come in and ask us, well should I do this stretch, or should I do that? What's the best way that I should sleep? How should I learn to walk on the steps? And then physical therapists are experts in that so I do encourage patients to do that, and I would say the vast majority do that after spinal fusion.
Sanjiv Lakhia: 27:50
Let's talk up a little bit on an issue that comes up for sure across the spinal literature in the decision making process. I really want to get your opinion on the concept of adjacent level disk disease. Because I'm asked quite a bit, all right what's the downside potentially of having my spine fused, this comes up. So I'd love to get your opinion on how big of an issue in the lumbar spine is the concept of adjacent level [inaudible 00:28:17] I guess first, if you could define that for the listeners who aren't aware of it, and then give us your opinion from your years of clinical practice.
Hunter Dyer: 28:26
Sure. So this is a very important topic and it comes up really with all patients that need either cervical or lumbar spinal fusion. What we are talking about is identifying the exact problem in a patient, so as an example, if we see a patient who's got instability between the fourth and fifth lumbar vertebrae, say they just had a weakness in their spine and developed what's called a spondylolisthesis, when one vertebrae is slightly in front of the other one. We know from years of research and data and many, many papers have been written, that when a patient finally fails all efforts at conservative measures and they've got back typically and leg pain, the treatment for a spondylolisthesis is to fuse that level, decompress the nerves, place screws into secure the L4 and L5 vertebrae.
But we have to warn the patients, depending on what age they are, and how the health of their spine is, that the levels next door to that, so if it's L4 and L5 getting fused together, what happens with L3 and L4 over the next 10 to 20 years. What happens with L5 S1, which is the disk space below L4-5. So that's what we are talking about with adjacent level problems.
And the reason for that is, Sanjiv, this again goes back to the analogy of the hip replacement, or the shoulder replacement, or the knee replacement. Those are surgeries for single joint levels, so when you have a spinal surgery, and if it's a fusion, it's not exactly the same as getting an artificial joint, but you're treating that one problem that [inaudible 00:30:08] area of the spine.
If you fuse the L4-5 level, that level no longer bends or moves, so as a result there are increased stresses on the adjacent levels as we get older. Now, if we start out before the surgery, and we look at the imaging study and the L3-4 level looks normal, the L5 S1 level looks normal, then it's probably not likely more than 10-12% risk of retirement, an adjacent level could become worse. The risk factors for adjacent level disease, or developing something later on, the biggest risk would be if you're having to have a level fused, and the next level is somewhat abnormal, it may not be bad enough to consider fusing two levels of the spine, but it might be somewhat abnormal.
We know that smoking is a big risk factor for spinal issues, both in the neck and the back. We typically do not like to even consider spinal fusion if somebody is using tobacco, but if they've used it in the past it's likely that they get degeneration of the disk and that can lead to accelerated adjacent level problems.
There are other risk factors including the size of the patient, the general nutrition that you talked about, conditioning, keeping the core muscles strong. So all of those things can be somewhat regulated but not entirely. We have patients that are extremely healthy, then do everything right, don't put their back at risk, but still can end up with adjacent level problems. Hopefully, not soon after a fusion, but more likely five, 10, 15 years after they've had a spinal fusion.
Sanjiv Lakhia: 31:53
Yes. Definitely a tricky topic to navigate. How I describe it to people, if I have a patient who is really struggling with a proven lumbar radiculopathy, I must say we've done conservative care, but we have EMG findings and they have denervation or evidence of nerve damage, I can tell them what I think is guaranteed to happen if you don't do anything, which would be pain, disability, nerve injury, maybe footdrop, and that I think that is fairly certain you're going to have to deal with.
In terms of lumbar fusion there's a possibility that just based upon the physics, that over time you'll have to have extension or further surgery, but I wouldn't necessarily say it's a probability at this point. Would you agree with that?
Hunter Dyer: 32:38
I would agree with that. We do many, many fusions without people having adjacent level problems, but there are people that have and I think they need to be warned about it. I tell people, I don't have a line of patients out of the front door of my office building waiting on a spinal fusion, because spinal fusion does change the native anatomy. It's makes a normally mobile segment stiff, so if you're fusing two vertebrae together, we're only doing that because of recalcitrant pain. People that have had previous surgery and have had failure. So the reasons that we do spinal fusion are really somewhat last resort, although in many, many people it can be a complete game changer, and we've seen pro-athletes return to sports, we've seen weekend athletes return to every thing they want to do, and that with a spinal fusion a lot of times, patients assume that that type of surgery would keep them from doing many of their normal activities, but I would say that many, many people are able to return to everything they want to do.
Sanjiv Lakhia: 33:50
I totally agree with that and again it's certainly not a decision you take lightly.
If you're just tuning in, we're wrapping up our show today, interview with Dr. Hunter Dyer, where he's breaking down everything you need to know about lumbar fusion surgery. I want to ask you a question, and just get your opinion on it. Why do you think in the community, and this is just my perception, and you can tell me you disagree with it. In the community, particularly with, I say, clinicians, not specialists, maybe primary care docs, the word fusion surgery has somewhat of a negative connotation and, for example, my brother is a hospitalist in traumas and physician in Cincinnati and when we talk about it, spinal fusions and his thoughts on it are, I think they are overdone. So where do you think this comes from and what would be your reaction to that.
Hunter Dyer: 34:45
Well, a couple of things. I would say one notion that presented itself in years past was when spinal fusion techniques really developed over the last 20 years, initially I do think surgeons did it too frequently and a lot of times they were doing that for back pain, when people didn't have significant leg pain, and so the lessons we learned on that were, we could make x-rays look better and we could make MRIs look better, but if people didn't have a significant component of leg pain, probably should be strong consideration to not do a spinal fusion.
I think another notion in the public is, when people meet somebody who's had neck or back surgery they do sometimes hear a story that they've had multiple procedures and that's not necessarily because they did poorly with whatever surgery they did, but because the spine is made up of so many different segments. So you can have a disk rupture when you're 35 at the L4-5 level, you get a pinched nerve, doesn't get better with conservative care, you have surgical treatment and it resolves the pain. Five years later you could have a disk that gave you trouble in your neck or a different level in the lumbar spine, but your neighbor, all they hear is that you're back in the spine surgeons office.
Well that's part of the reason that the human spine is very complex because you've got seven cervical segments and 12 thoracic segments and five lumbar segments, so these are all each individual disk levels that can affect a nerve. In all of us, in fact, as we get older it's really rare that we don't experience back pain or neck pain or nerve pain in our lifetime. It happens to almost all Americans. There are different reasons that that word gets out there and whatever you can do, try to avoid spine surgery. I totally agree with that. I tell all my patients if we can keep you out of the OR that's what we want to do. Nobody wants to have surgery for anything, but ultimately a lot of people need to have it and fortunately most people are significantly improved.
Sanjiv Lakhia: 36:52
That's a great answer. Thank you for that.
As a wrap up, where are we heading with spine surgery from a technology perspective and with regards to lumbar fusion. Are there some things that we should be looking out for?
Hunter Dyer: 37:06
Well, I think we've seen incredible progress over the last five years, specially. When I spoke about anterior, lateral and posterior fusion techniques, I'm not even getting in to the fact that we can now do this minimally invasive. We can put screws in without making larger incisions, so there are newer techniques that we do. There also are incredible advances in what we call navigation, so basically with navigation we can take an imaging study and we can take the imaging study and basically attach the instruments to the imaging study. In other words, we can take a screw driver off the back table and when we put it on the patient's spine we can look at the screen and see the MRI or CT images to know exactly where to put the screw.
The other thing that's come along, is we're doing some of these surgeries with robotics now, so we can use robotic tools that again use the navigation systems, place the pedicle screws into the proper position, so the advances in technology have been remarkable really in many, many surgical specialties. In spine surgery, we're seeing a very steep increase in navigation tools, that make surgery safer, more precise. We can make smaller incisions, we see spinal fractures all the time over at the hospital at the trauma center and we are able to fix many of the spinal fractures with less invasive techniques that we did in the past. These make for, usually quicker healing and less pain, and for many people it's just a better thing all around.
So what else might be coming? We're certainly wonder whether there might be more injectable treatments. Will there be things that allow us to avoid placing as much instrumentation over time? I think there are evolving techniques with that and we're excited about that. Innovation is really the key in surgical specialties. We really depend on innovation to get things better and in my 25 years it's been nothing short of remarkable to watch the progress that we've seen with device companies. The technology is just fascinating in the surgical field, as in physiatry and others, we're learning every day which is great for patients and great for us.
Sanjiv Lakhia: 39:42
Definitely exciting times and if you want to learn a little more, I did a podcast interview with Dr. Chris Hall on the idea of robotics specifically, so we'll link to that in the show notes. So I think the take home is just stay tuned. If you're out there, there are brilliant minds working every day to advance the field of surgical and non-surgical spine care.
Hunter, thanks for your time today. I really appreciate you taking time to talk about this. As a wrap up, I always like to share with our listeners just some general health tips. You are president of our group, and by all accounts we are a big group and we're not so easy to manage. You tackle that, you're on numerous executive committees, hospital committees, different boards, so you don't get to be in a successful position without having some personal health strategies, or daily routines, or health habits, lifestyle habits. Are there any tips you want to share with the listeners that you have done over the years that's helped you, that someone else could benefit from?
Hunter Dyer: 40:43
Sure. Well, I think, like a lot of surgeons, I'm lucky in that I don't require a ton of sleep, but I get the sleep that I need, and I do remain active all the time. I'm not the best example of somebody who is an extremely regular exercise person, but I stay on the go and I think my metabolism stays at a high rate, which helps. And then I lean on having great family support. I've got a great wife and kids, and also the key to any great job, or being good at what you do, is I absolutely love what I do, so I wake up every single day excited to see what I've got for the day and see if I can help people surgically, to see if I can help people in the clinic, and that's why we love being physicians and we love being in healthcare, because it's just so rewarding.
There's no year in which it was better exemplified than from all the people in healthcare that have helped patients in crisis with Covid, and certainly as a neurosurgeon I would say my role in that was very minimal, but it points out just how great it is to be in healthcare. To me there is no better thing to do in a life.
Sanjiv Lakhia: 41:54
I totally agree with that, and I'll close with a story.
I don't know if you recall, but people are really trying to understand a little more about you, but when I joined the crew, I think it was within a few months we had a retreat and, folks, I get paired up with Hunter for some golf and I am not a golfer, and I asked him, we're about to tee off, and Hunter, I don't know if you recall, I was like, do you play and you're like, yes, a little bit. So you teed off and you took your swing and the ball went on a straight line, about 300 yards, I don't know how far because I couldn't see it anymore, it had gone so far, and you just bent over and picked up your tee and you were like, kind of like a lucky shot, right.
So, I'm pretty nervous, I just joined the group and I think everyone else was watching us because we were the first pair and I put the ball down, and I teed off and thank the Lord I actually hit the ball and it went straight, probably about 160 yards, and everyone else moved on and wouldn't you know it, that was the only time the entire day, that I hit the ball flush, and you were so gracious with it. I think by the 16th hole you had me at least driving the cart, because I'd run out of balls.
But you don't that, but I went home and I told my wife, don't unpack because I don't know how long I'm going to be here.
Hunter Dyer: 43:08
Well if we chose our physicians based on their golf skills, it would be a very small group, that's for sure.
Sanjiv Lakhia: 43:15
Yes, it's good. I know you love to play golf and tennis and other things, so staying active is a big part of staying healthy on top of things.
Hunter Dyer: 43:15
Absolutely.
Sanjiv Lakhia: 43:22
So thanks again today for your time. If you liked this episode feel free to leave us a comment. Five star review on iTunes. It helps us with our ranking, and give us feedback if you love the message we're trying to spread, or if you have other questions, feel free to reach out to me at backtalkdoc.com and Hunter, one again, thank you for your time. I really enjoyed the interview.
Hunter Dyer: 43:43
Thank you.
Outro: 43:46
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 at carolinaneurosurgery.com.
This podcast is sponsored by our partner, QXMD. QXMD builds mobile solutions that drive evidence based medicine in clinical practice. Check out READ for easy access to research personalized for you, and CALCULATE for over 500 easy to use decision support tools. Try them today at QXMD.com/apps. Again, that is QXMD.com/apps.
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: 01:04
As a board certified physiatrist I do feel like it's may day-to-day job to try and help patients to avoid surgery, particularly spine surgery, as that's the majority of my practice. But obviously not everyone can avoid surgery and on Back Talk Doc we've had several great interviews dealing with the idea of spine surgery.
If you haven't had a chance, please go back and check out my episode where I interview Dr. Mark Smith about minimally invasive spinal surgical techniques, and also listen to the interview that I do with Dr. Joe Cheatle where we talked about lumbar stenosis, and he reviewed definitely some surgical techniques as well.
But today I'm delighted to jump into the topic of lumbar spinal fusion surgery and I want to welcome my guest Dr. Hunter Dyer to the show. Hunter welcome to the show.
Hunter Dyer: 01:57
Thank you. Good to be here.
Sanjiv Lakhia: 01:58
Now Hunter is the president of our group at Carolina Neurosurgery and Spine Associates, and he's had a long distinguished career and continues to rack up accolades. His specialty interests are degenerative spine disease, endoscopic spine surgery, minimally invasive spine surgery. He also does skull based surgery, spinal fusions, as well as many other things.
Educationally, he went to medical school at the University of Mississippi. He did residency and internship at the University of Texas South Western medical center, Dallas, and he did a fellowship in pituitary and skull based surgery, and did some training in France.
So, he is one of the most distinguished neurosurgeons in the Charlotte area, if not nationally, and he has graciously volunteered his time to help educate us today on the topic of spinal fusion surgery. But before we dive into that, for those in the community who are listening who don't know you all that well, feel free to elaborate on your background and maybe share on your path to the field of neurosurgery.
Hunter Dyer: 03:01
Absolutely. Happy to.
So, as Sanjiv said, I did my medical school in Mississippi and then went to Texas for my training. I was fortunate in that my training there, I had one of my current partners, Dr. Tim Adamson, who was in residency with me there, and so he talked me into looking at this practice in Charlotte, and fortunately for me it worked out great. We've enjoyed being in Charlotte over the last 26 years and we've been able to build a fantastic practice and it's just been a great place to work and we enjoy it to this day.
Sanjiv Lakhia: 03:39
Now in your day to day practice what percent of patients that you see, would you estimate, end up needing a lumbar fusion surgery?
Hunter Dyer: 03:49
Right. Well, I'd like to say first, when people think of neurosurgeons we're known for our cranial treatment, whether it's head injury, other problems of the brain, and for being a brain surgeon. But in reality neurosurgeons spend at least 70%, sometimes up to 80% or 85%, of their time taking care of spinal problems. So, when I see office twice a week, the majority of my patients have problems of the cervical or lumbar spine primarily, and that is across the board the way it is for all neurosurgeons around the country. Spinal issues are just much more common than cranial issues. Certainly when we are on call at night we see a lot of cranial problems that come through the hospital, and we do see some in our day to day practice in the office, but spinal issues are extremely common and spinal fusion is one of those things that we see really on a daily basis in the office setting.
Sanjiv Lakhia: 04:46
Yes, for sure. It's the whole basis for the podcast. The burden of spine care in this country is just enormous and we've outlined on previous episodes a lot of the non-surgical approaches that a fantastic podcast with Dr. Vemuri where we talked about the surgical spine. I did one with Dr. Otis on the thoracic spine and I've done one with Dr. Sumich on lumbar injections. But I will tell you in terms of interest, there is no shortage of interest in the public when it comes to spine surgery and in particular, patients that I encounter on a day to day basis, or even friends or family, they want to know just a couple of things. They want to know what's new and how quick can I recover. I think the answer to those questions, it will be helpful to the listeners if you could walk us down the path in a typical daily [inaudible 00:05:41]. Someone comes in to see you. How are you evaluating people from a surgical perspective before we even get to the idea of discussing lumbar fusion?
Hunter Dyer: 05:50
Sure. Well first of all, even for a surgeon, the majority of spinal issues that we see are things that can be dealt with, with conservative care. So everybody we see, again even as a surgeon we're saying, have you done physical therapy, have you done traction, have you done injections, how long has it been that you've had symptoms, have you had any previous procedures? So part of the history is making sure that they even need to begin a discussion about surgery or not.
Now, as far as a fusion goes, especially in the lumbar spine, there are many, many people that have symptoms that pertain to just a single nerve root in the lower back. And by that I'm talking about pressure on either one of the nerve roots that forms the sciatic nerve, most people are familiar with that type of pain that goes down from the lower back to the buttock and then all the way down the leg, typically to the foot or the ankle. Some people have pressure on the nerve root in their lower back that affects the femoral nerve, that goes again down the buttock, typically down the front of the thigh, sometimes past the knee, even down along the shin.
So, when people have that type of a pinched nerve symptom, the majority of people are able to try conservative care first. If that doesn't work there are many, many minimally invasive procedures where we can isolate a single nerve that's pinched, and surgically decompress that nerve.
The only people that we need to consider for spinal fusion are typically those that have problems where they require so much bone removal that they require stabilization of the spine. So, spinal fusion involves trying to get vertebrae in the spinal elements to grow together, to grow bone to connect a segment, or two, of the spine.
So we try to isolate first of all, have they done everything they can, short of surgery? Can they be evaluated for minimum invasive surgery, and then if they cannot, is it something that can be considered for spinal fusion?
Sanjiv Lakhia: 08:03
One thing I would say is, let's walk it back just a touch, and my audience is a mixture of people in the public who love to listen to the podcasts, also clinicians, but can you give us a basic definition of what fusion means. When you say lumbar fusion, help people understand what exactly that term implies.
Hunter Dyer: 08:23
Right. So when we tell people, or talk to people, about lumbar fusion, often there's a misperception that if you speak about lumbar fusion, you're talking about putting in hardware in the back, in the spine. If you put a hardware in is that actually the fusion? And that's where the misperception usually falls. People think that if you are getting screws and two connecting rods on each side, that's fusing the spine. In fact what the hardware does, is just hold the spine in proper alignment until bony growth is achieved. So the fusion is actually the growth between, or around, the spinal elements, whether it's the vertebrae growing together, or whether it's the spinal elements in the back part of the spine that grow together.
Typically, people that have spinal instrumentation put in, have bone graft material put in also. The bone graft material can be, it's usually bone that we take out of the spine and reintroduce to the spine to try to get it to fuse, or it includes other bone products that encourage bone growth.
So I try to clarify that with patients quickly because it is such a common notion that patients have that when they get spinal instrument put in that that actually is the fusion, but the spinal fusion is actually the growth of bone to connect that part of the spine. To make it no longer mobile.
Sanjiv Lakhia: 09:51
That's an excellent clarification, thank you for that.
And then I want to respond to what you said earlier. What I like to tell patients is that with surgery, if it gets to the point where they have to remove enough bone, it can create an environment that's slightly unstable. Something akin to, if you take too many bricks out of a foundation of a home, it can make it unsteady. So what you are doing there, if I am hearing correctly, is the hardware comes into play when you've made a medical assessment of the situation into freeing up a nerve or two, is going to require enough of an intervention that it could create almost an unstable environment, and that's where you have to then insert the hardware. Is that reasonably accurate?
Hunter Dyer: 10:39
That's exactly right. So we have two different types of instability. One in which a patient who's not had any procedures, and has not had any intervention, comes in and we can do x-rays of the spine, with a person leaning forward and backwards, and we see instability where the spinal vertebrae are actually moving. And that results from degeneration of the joints in the spine that connect one vertebrae to the next. That's one type of instability.
The other type you mention is that, if we actually have to remove excessive bone to free up the nerves, then we are basically creating an unstable situation in which we have to secure the spinal segments.
Now, I'm always quick to tell my patients, one thing that's complicated about the spine is that every vertebral segment in the spine has a joint that can exit to the next. Some people think, well gosh, this must be an analogous to get my knee replaced, or my hip replaced. Well those are single joints that can actually be replaced, and can work in an analogous way to the way they did prior to replacement.
With the spine we are usually addressing one or more segments of the spine but they're still many mobile segments above and below. So in other words, if we have to do a spinal fusion, it might be between lumbar segments three and four, and that makes that level no longer a moveable segment, but there's still motion in all the segments above and below.
So, another common misperception is that if you have a spinal fusion, that you look different, or that you're stiff looking, or that you can't lean over and tie your shoes, and of course that's certainly not the case. There are people that have larger fusion procedures for problems like scoliosis where they could have a much longer segment of their spine that's fused, but in the vast majority of people, you're talking about one or two spinal segments.
Sanjiv Lakhia: 12:40
You mentioned before, the idea of someone coming in with a trapped nerve root which would certainly cause a lot of pain going down the leg. Do you consider low back pain... are there situations where low back, without the leg symptoms, is an indication possibly for lumbar fusion surgery?
Hunter Dyer: 13:00
The number of times that we do spinal fusion surgery, just for lower back pain is certainly much less than it was, say 10 or 15 years ago. The reasons for that are, we know that with the majority of the spinal surgery we do is essentially for leg pain because of a pinched nerve. Now when we were talking about spinal fusion surgery, even though we're putting in instrumentation and getting the spine to remain stable by having the bone grow there, the first part of almost every spinal fusion surgery involves decompressing the nerves and making sure the nerve pain is resolved. So, I tell people when they're having a spinal fusion that I spend the first 30 minutes to an hour making sure the nerves are free, taking off the amount of bone I'd need to resolve that part of the pain, and then the second part of the operation, putting in the instrumentation and completing the spinal fusion.
But the number of people that we know from research, and from years of data, that we have to be extremely selective about recommending spinal fusion if somebody only has back pain. And the reasons for that are that back pain can be multi-factorial. We know that people get arthritis as they get older. It's very hard to look at an imaging study and say well I'm going to do a spinal fusion at L3-4 because I think most of your back pain is coming from that. It's hard to localize because people that are in the age groups that typically would have a spinal fusion, may have arthritis at multiple levels.
We certainly don't want to offer surgery when we can't be reasonably sure that we're significantly going to improve the pain, or improve the problem.
Sanjiv Lakhia: 14:48
That's a great clarification. I also liked your comparison to orthopedic total joint surgery. It's just a different beast, there's different physics involved, different degrees of freedom and motion, so that's a good take on point if you're listening. It's really not akin to...we don't call it spine replacement surgery, like you call it hip replacement, or knee replacement surgery. So there's definitely a lot more involved to it.
Now, let's get into a little bit, there's almost an alphabet soup of acronyms for lumbar fusions the ALIF, TLIF, BLIF. Can you walk people through the different approaches to fusion and maybe some of those indications and what sets them apart?
Hunter Dyer: 15:33
Sure. It's not as easy to do on an audio broadcast, but I'll try to explain the different approaches that we consider for spinal fusion. The spine can be approached from the front, the lumbar spine specifically. That can be done through a trans-abdominal route, so the front of the vertebrae are actually at the back of the abdominal cavity, so spinal fusion for lumbar segments for L3-4, L4-5, and that's what we call an ALIF, the A being anterior, LIF being lumbar interbody fusions, so we can go in through the front. We can take out the spinal disk between two vertebrae, we can place an implant such as a cage between them and typically a plate on the front.
It's a very good way to have a spinal fusion that provides what we call an indirect decompression of the nerves, and by that when go from the front, we're not directly looking at the nerves, but if we take a very narrow disk space and open it up, we do create more space for nerves and that typically will relieve nerve pain.
So that's one type of spinal fusion. We also do a lateral spinal fusion which is done directly from the patient's side, right below the rib cage. This is usually done in the upper and mid-lumbar spine from about lumbar 1-2, down to 2-3, 3-4, sometimes 4-5. That is a way that we can also go into the disk space, we can put a large cage across the disk space and that provides, again, that indirect decompression where we are opening up the disk space, essentially jacking it up, where it's taller, and that provides freedom for the nerves coming out of the spine.
So both the ALIF and the, we call it an XLIF, which is a lateral approach, those are both commonly used. The most common procedure, however, is done from the back and that is when we go in and we have direct view of the spinal nerves because we are operating from the posterior approach we can see the spinal canal, we an actually follow each of the nerve roots out as they go below the pedicles, which are the prominent pieces of bone that connect the front and the back part of the spine. We decompress the nerves and then we can place screws into the pedicle which then go into the vertebrae. So those are called the pedicle screws and then we connect those with short rod segments. So those are called posterior lumbar interbody fusions, typically because we go in from a posterior approach, we place those cages in the disk space. So each of the fusions that I describe usually involve placement of interbody or cages in the disk space. Interbody referring to between the vertebral bodies.
That's probably the most common form of a fusion done in the United States at this point. And again you can do an interbody fusion from an anterior, from a lateral side approach, or from the posterior approach.
Sanjiv Lakhia: 18:37
That leads me into my next question. Do the recovery times, the healing times, differ based upon if you come from the front, the side or the back?
Hunter Dyer: 18:49
They do vary somewhat. I would say that the posterior approach, because we have to separate the muscles of the spine typically to get the materials in there, and get the nerves freed up, that muscle pain is probably more when we do it from a posterior approach. From a lateral approach there's not a lot of pain. From the anterior approach there's some pain going through the abdominal cavity and we typically do that in combination with a vascular surgeon because of the blood vessels that are in front of the spine.
So each of these approaches has its advantages and disadvantages. Sometimes people even have a combination of approaches. If they have to have a spinal fusion and they have a curvature of their spine sometimes there's an advantage to going either from the front and the back, or the side and the back. And those are a little bit larger type procedures, but those have very specific indications. It can be quite helpful for the right problem. But in general there's more pain with the posterior approach, but it's still the most common way because it does provide that direct view of the nerves. If people have extreme pressure on the nerves and they've got either disk rupture, or they've got cyst formation pinching the nerves, we really want to see those nerves directly and so we choose a posterior approach when we have to deal with that.
Sanjiv Lakhia: 20:12
Actually I do get questions from patients about, if I refer to one of my colleagues, does that surgeon do this approach, and I think if you're listening to Dr. Dyer break this down, what's clear to me is, it is a complex decision and you have to have someone who certainly has expertise in it and sounds this is a case by case scenario versus making a blanket statement that one approach is necessarily better than the other.
Hunter Dyer: 20:39
It really is. You really look at a patient's problem and there's so many different factors. Some of the factors that we are concerned about are, what is the body habitus, is the patient thin, is the patient heavy? And number two, has the patient had previous surgical treatment? If there's a lot of scar tissue from a previous approach, sometimes that can make us go from a different direction.
Scoliosis is important, so we frequently get scoliosis x-rays to make sure patients don't need something different, because if you get x-rays to look for curvature in the spine, sometimes that can change the approach that we make.
The other factor, of course, is what I talked about with the pinched nerves. If you know you can go from the front or the side and get that indirect decompression of the nerves, but is indirect compression enough. Do we need to go from posterior approach so that we can directly look at the nerves and make sure they're freed up. If we do a great spinal fusion surgery and the x-rays look wonderful and we do not get that nerve decompressed, we are not going to have a patient that has the type improvement that we want. And I can tell you that after doing this for 25 years, we have no other goal than getting a patient better as it is absolutely terrible when a patient has to go through a procedure like that, that causes pain, and they're not enough improved.
So I only get satisfaction, I think everybody would say this, when a patient achieves both a really graphic improvement in the x-rays, but most importantly in their symptomatology. If they come into my office with back pain, and leg pain that's refractory to conservative measures I want to offer them a procedure that's going to make them better. Not just the x-rays, but how they are symptomatically.
Sanjiv Lakhia: 22:28
Yes, that's great. You almost start echoing when I interviewed Mark Smith. He basically made a comment that minimally invasive is great, if it works, and that's what they need, but you're not doing anyone a favor by basically under operating, so to speak. So the primary goal here, to emphasize, is clinical improvement and these are different cervical techniques and tools we have available, that he felt like his job, as you just basically articulated, is to keep his eye on the ball and help the patient get better and use what's most appropriate.
I talk with patients about that, where I mention I want refer them onto surgery and they're like, well I don't want to have anything done major, and I say, well no one wants to, but at the end of the day, the deal breaker is living a life of disability, poor function and chronic pain. That's the deal breaker to me. So, I'm glad you articulated it in that way. I think that's a lens we should be looking at these problems through.
Now, someones come to you, you've [inaudible 00:23:29] down, let's say a one level fusion, let's say between L4 and L5, people want to know, how long am I out. What's your talking points for the recovery piece, are we talking three to six months, lifting restrictions. Break that down for us.
Hunter Dyer: 23:44
Right. I would say with the standard posterior approach I usually tell people that they can expect muscle type pain anywhere from 10 days to two weeks, typically. Now, those people are obviously not in a hospital setting for that period of time, so they usually go home with some medication and with muscle relaxers. We do have them ambulating, even the first day after surgery, so if they have their surgery as an inpatient in the hospital, they're usually getting up the next day with physical therapy.
I did two lumbar fusions today and I told both of them they would be up either later today, or in the morning. It's very important for them to get up moving quickly. The muscle pain is treated with medication. It certainly is somewhat worse right after surgery than what you experienced before, so I'm careful to make sure my patients know that in the first few days, or the first week, they shouldn't be terribly alarmed that they have more pain really than they did before. Maybe not the nerve pain, hopefully, but they've got pain localized to the back muscles and to the back, and that is simply post-operative pain. So typically that gets better.
I tell people that they can expect to be, really at three to four weeks, to recognize that they're much better than they were before surgery, and to expect to really feel like that they're over the surgery as far as energy level, getting up and around, not having that type of pain that they had before, at the two month period.
Sanjiv Lakhia: 25:15
Fantastic.
Hunter Dyer: 25:16
I also tell people that as far as the spinal fusion... it depends on the age. Spinal fusion we talked about growing bone in the spine around the area that's operated and that depends entirely on your bone metabolism, which is variable in everybody. If we have to do a spinal fusion on somebody that's very young, in their 20s or 30s, which would be unusual, they would likely form a fusion very quickly, possibly in 30 to 45 days. If we do it in somebody in their 40s or 50s, it's a little bit longer. If we have to do spinal fusion in somebody that has marginal bone metabolism, or doesn't grow bone as well, perhaps in their perimenopausal age, or even older, then we're looking at following x-rays sometimes for six months or even a year to make sure that we achieve adequate bone healing.
Sanjiv Lakhia: 26:06
This is where the idea of healthy lifestyle comes in to play, and I discuss with patients all the time that it's so important to eat well, get adequate nutrition, weight bearing exercise, and even if those things don't fix your back pain, let's say you do end up down the road needing surgery and potentially a fusion, what you just outlined there, healthy bone metabolism that is largely driven by the food we eat, the exercise, not smoking and things like that, so that's why I like to talk about the lifestyle piece on this show quite a bit because I see it play out day-to day.
So now let's say people have done well, they're about one to two months out. Do you typically recommend physical therapy, or is that case by case?
Hunter Dyer: 26:53
I would say the majority of patients that have spinal fusion, regardless of the approach, they do benefit from physical therapy. We do it in the hospital setting while they're there. Typically let the wound heal and let them get a little bit over the muscle soreness before we put them into more aggressive therapy, but I think it allows them to progress at a faster rate. I think it does help improvement after surgery.
Surgeons and physiatrists at the most part don't know all of the exercises, the muscle conditioning, the things that should tell patients as they're recovering, so patients like to come in and ask us, well should I do this stretch, or should I do that? What's the best way that I should sleep? How should I learn to walk on the steps? And then physical therapists are experts in that so I do encourage patients to do that, and I would say the vast majority do that after spinal fusion.
Sanjiv Lakhia: 27:50
Let's talk up a little bit on an issue that comes up for sure across the spinal literature in the decision making process. I really want to get your opinion on the concept of adjacent level disk disease. Because I'm asked quite a bit, all right what's the downside potentially of having my spine fused, this comes up. So I'd love to get your opinion on how big of an issue in the lumbar spine is the concept of adjacent level [inaudible 00:28:17] I guess first, if you could define that for the listeners who aren't aware of it, and then give us your opinion from your years of clinical practice.
Hunter Dyer: 28:26
Sure. So this is a very important topic and it comes up really with all patients that need either cervical or lumbar spinal fusion. What we are talking about is identifying the exact problem in a patient, so as an example, if we see a patient who's got instability between the fourth and fifth lumbar vertebrae, say they just had a weakness in their spine and developed what's called a spondylolisthesis, when one vertebrae is slightly in front of the other one. We know from years of research and data and many, many papers have been written, that when a patient finally fails all efforts at conservative measures and they've got back typically and leg pain, the treatment for a spondylolisthesis is to fuse that level, decompress the nerves, place screws into secure the L4 and L5 vertebrae.
But we have to warn the patients, depending on what age they are, and how the health of their spine is, that the levels next door to that, so if it's L4 and L5 getting fused together, what happens with L3 and L4 over the next 10 to 20 years. What happens with L5 S1, which is the disk space below L4-5. So that's what we are talking about with adjacent level problems.
And the reason for that is, Sanjiv, this again goes back to the analogy of the hip replacement, or the shoulder replacement, or the knee replacement. Those are surgeries for single joint levels, so when you have a spinal surgery, and if it's a fusion, it's not exactly the same as getting an artificial joint, but you're treating that one problem that [inaudible 00:30:08] area of the spine.
If you fuse the L4-5 level, that level no longer bends or moves, so as a result there are increased stresses on the adjacent levels as we get older. Now, if we start out before the surgery, and we look at the imaging study and the L3-4 level looks normal, the L5 S1 level looks normal, then it's probably not likely more than 10-12% risk of retirement, an adjacent level could become worse. The risk factors for adjacent level disease, or developing something later on, the biggest risk would be if you're having to have a level fused, and the next level is somewhat abnormal, it may not be bad enough to consider fusing two levels of the spine, but it might be somewhat abnormal.
We know that smoking is a big risk factor for spinal issues, both in the neck and the back. We typically do not like to even consider spinal fusion if somebody is using tobacco, but if they've used it in the past it's likely that they get degeneration of the disk and that can lead to accelerated adjacent level problems.
There are other risk factors including the size of the patient, the general nutrition that you talked about, conditioning, keeping the core muscles strong. So all of those things can be somewhat regulated but not entirely. We have patients that are extremely healthy, then do everything right, don't put their back at risk, but still can end up with adjacent level problems. Hopefully, not soon after a fusion, but more likely five, 10, 15 years after they've had a spinal fusion.
Sanjiv Lakhia: 31:53
Yes. Definitely a tricky topic to navigate. How I describe it to people, if I have a patient who is really struggling with a proven lumbar radiculopathy, I must say we've done conservative care, but we have EMG findings and they have denervation or evidence of nerve damage, I can tell them what I think is guaranteed to happen if you don't do anything, which would be pain, disability, nerve injury, maybe footdrop, and that I think that is fairly certain you're going to have to deal with.
In terms of lumbar fusion there's a possibility that just based upon the physics, that over time you'll have to have extension or further surgery, but I wouldn't necessarily say it's a probability at this point. Would you agree with that?
Hunter Dyer: 32:38
I would agree with that. We do many, many fusions without people having adjacent level problems, but there are people that have and I think they need to be warned about it. I tell people, I don't have a line of patients out of the front door of my office building waiting on a spinal fusion, because spinal fusion does change the native anatomy. It's makes a normally mobile segment stiff, so if you're fusing two vertebrae together, we're only doing that because of recalcitrant pain. People that have had previous surgery and have had failure. So the reasons that we do spinal fusion are really somewhat last resort, although in many, many people it can be a complete game changer, and we've seen pro-athletes return to sports, we've seen weekend athletes return to every thing they want to do, and that with a spinal fusion a lot of times, patients assume that that type of surgery would keep them from doing many of their normal activities, but I would say that many, many people are able to return to everything they want to do.
Sanjiv Lakhia: 33:50
I totally agree with that and again it's certainly not a decision you take lightly.
If you're just tuning in, we're wrapping up our show today, interview with Dr. Hunter Dyer, where he's breaking down everything you need to know about lumbar fusion surgery. I want to ask you a question, and just get your opinion on it. Why do you think in the community, and this is just my perception, and you can tell me you disagree with it. In the community, particularly with, I say, clinicians, not specialists, maybe primary care docs, the word fusion surgery has somewhat of a negative connotation and, for example, my brother is a hospitalist in traumas and physician in Cincinnati and when we talk about it, spinal fusions and his thoughts on it are, I think they are overdone. So where do you think this comes from and what would be your reaction to that.
Hunter Dyer: 34:45
Well, a couple of things. I would say one notion that presented itself in years past was when spinal fusion techniques really developed over the last 20 years, initially I do think surgeons did it too frequently and a lot of times they were doing that for back pain, when people didn't have significant leg pain, and so the lessons we learned on that were, we could make x-rays look better and we could make MRIs look better, but if people didn't have a significant component of leg pain, probably should be strong consideration to not do a spinal fusion.
I think another notion in the public is, when people meet somebody who's had neck or back surgery they do sometimes hear a story that they've had multiple procedures and that's not necessarily because they did poorly with whatever surgery they did, but because the spine is made up of so many different segments. So you can have a disk rupture when you're 35 at the L4-5 level, you get a pinched nerve, doesn't get better with conservative care, you have surgical treatment and it resolves the pain. Five years later you could have a disk that gave you trouble in your neck or a different level in the lumbar spine, but your neighbor, all they hear is that you're back in the spine surgeons office.
Well that's part of the reason that the human spine is very complex because you've got seven cervical segments and 12 thoracic segments and five lumbar segments, so these are all each individual disk levels that can affect a nerve. In all of us, in fact, as we get older it's really rare that we don't experience back pain or neck pain or nerve pain in our lifetime. It happens to almost all Americans. There are different reasons that that word gets out there and whatever you can do, try to avoid spine surgery. I totally agree with that. I tell all my patients if we can keep you out of the OR that's what we want to do. Nobody wants to have surgery for anything, but ultimately a lot of people need to have it and fortunately most people are significantly improved.
Sanjiv Lakhia: 36:52
That's a great answer. Thank you for that.
As a wrap up, where are we heading with spine surgery from a technology perspective and with regards to lumbar fusion. Are there some things that we should be looking out for?
Hunter Dyer: 37:06
Well, I think we've seen incredible progress over the last five years, specially. When I spoke about anterior, lateral and posterior fusion techniques, I'm not even getting in to the fact that we can now do this minimally invasive. We can put screws in without making larger incisions, so there are newer techniques that we do. There also are incredible advances in what we call navigation, so basically with navigation we can take an imaging study and we can take the imaging study and basically attach the instruments to the imaging study. In other words, we can take a screw driver off the back table and when we put it on the patient's spine we can look at the screen and see the MRI or CT images to know exactly where to put the screw.
The other thing that's come along, is we're doing some of these surgeries with robotics now, so we can use robotic tools that again use the navigation systems, place the pedicle screws into the proper position, so the advances in technology have been remarkable really in many, many surgical specialties. In spine surgery, we're seeing a very steep increase in navigation tools, that make surgery safer, more precise. We can make smaller incisions, we see spinal fractures all the time over at the hospital at the trauma center and we are able to fix many of the spinal fractures with less invasive techniques that we did in the past. These make for, usually quicker healing and less pain, and for many people it's just a better thing all around.
So what else might be coming? We're certainly wonder whether there might be more injectable treatments. Will there be things that allow us to avoid placing as much instrumentation over time? I think there are evolving techniques with that and we're excited about that. Innovation is really the key in surgical specialties. We really depend on innovation to get things better and in my 25 years it's been nothing short of remarkable to watch the progress that we've seen with device companies. The technology is just fascinating in the surgical field, as in physiatry and others, we're learning every day which is great for patients and great for us.
Sanjiv Lakhia: 39:42
Definitely exciting times and if you want to learn a little more, I did a podcast interview with Dr. Chris Hall on the idea of robotics specifically, so we'll link to that in the show notes. So I think the take home is just stay tuned. If you're out there, there are brilliant minds working every day to advance the field of surgical and non-surgical spine care.
Hunter, thanks for your time today. I really appreciate you taking time to talk about this. As a wrap up, I always like to share with our listeners just some general health tips. You are president of our group, and by all accounts we are a big group and we're not so easy to manage. You tackle that, you're on numerous executive committees, hospital committees, different boards, so you don't get to be in a successful position without having some personal health strategies, or daily routines, or health habits, lifestyle habits. Are there any tips you want to share with the listeners that you have done over the years that's helped you, that someone else could benefit from?
Hunter Dyer: 40:43
Sure. Well, I think, like a lot of surgeons, I'm lucky in that I don't require a ton of sleep, but I get the sleep that I need, and I do remain active all the time. I'm not the best example of somebody who is an extremely regular exercise person, but I stay on the go and I think my metabolism stays at a high rate, which helps. And then I lean on having great family support. I've got a great wife and kids, and also the key to any great job, or being good at what you do, is I absolutely love what I do, so I wake up every single day excited to see what I've got for the day and see if I can help people surgically, to see if I can help people in the clinic, and that's why we love being physicians and we love being in healthcare, because it's just so rewarding.
There's no year in which it was better exemplified than from all the people in healthcare that have helped patients in crisis with Covid, and certainly as a neurosurgeon I would say my role in that was very minimal, but it points out just how great it is to be in healthcare. To me there is no better thing to do in a life.
Sanjiv Lakhia: 41:54
I totally agree with that, and I'll close with a story.
I don't know if you recall, but people are really trying to understand a little more about you, but when I joined the crew, I think it was within a few months we had a retreat and, folks, I get paired up with Hunter for some golf and I am not a golfer, and I asked him, we're about to tee off, and Hunter, I don't know if you recall, I was like, do you play and you're like, yes, a little bit. So you teed off and you took your swing and the ball went on a straight line, about 300 yards, I don't know how far because I couldn't see it anymore, it had gone so far, and you just bent over and picked up your tee and you were like, kind of like a lucky shot, right.
So, I'm pretty nervous, I just joined the group and I think everyone else was watching us because we were the first pair and I put the ball down, and I teed off and thank the Lord I actually hit the ball and it went straight, probably about 160 yards, and everyone else moved on and wouldn't you know it, that was the only time the entire day, that I hit the ball flush, and you were so gracious with it. I think by the 16th hole you had me at least driving the cart, because I'd run out of balls.
But you don't that, but I went home and I told my wife, don't unpack because I don't know how long I'm going to be here.
Hunter Dyer: 43:08
Well if we chose our physicians based on their golf skills, it would be a very small group, that's for sure.
Sanjiv Lakhia: 43:15
Yes, it's good. I know you love to play golf and tennis and other things, so staying active is a big part of staying healthy on top of things.
Hunter Dyer: 43:15
Absolutely.
Sanjiv Lakhia: 43:22
So thanks again today for your time. If you liked this episode feel free to leave us a comment. Five star review on iTunes. It helps us with our ranking, and give us feedback if you love the message we're trying to spread, or if you have other questions, feel free to reach out to me at backtalkdoc.com and Hunter, one again, thank you for your time. I really enjoyed the interview.
Hunter Dyer: 43:43
Thank you.
Outro: 43:46
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 at carolinaneurosurgery.com.
Top quotes from the episode:
[14:00] “We have to be extremely selective about recommending spinal fusion if somebody only has back pain. … We certainly don't want to offer surgery when we can't be reasonably sure that we're significantly going to improve the pain, or improve the problem.”
[30:57] “We know that smoking is a big risk factor for spinal issues, both in the neck and the back. We typically do not like to even consider spinal fusion if somebody is using tobacco. But if they've used it in the past, it's likely that they get degeneration of the disk and that can lead to accelerated adjacent-level problems.”
[32:51] “I don't have a line of patients out of the front door of my office building waiting on a spinal fusion because spinal fusion does change the native anatomy. It makes a normally mobile segment stiff, so if you're fusing two vertebrae together, we're only doing that because of recalcitrant pain.”
[33:16] “The reasons that we do spinal fusion are really somewhat last resort, although in many, many people it can be a complete game changer. We've seen pro athletes return to sports, we've seen weekend athletes return to everything they want to do. With a spinal fusion a lot of times, patients assume that that type of surgery would keep them from doing many of their normal activities. But I would say that many people are able to return to everything they want to do.”
[39:12] “Innovation is really the key in surgical specialties. We really depend on innovation to get things better and in my 25 years it's been nothing short of remarkable to watch the progress that we've seen with device companies. The technology is just fascinating in the surgical field [which] is great for patients and great for us.”
[14:00] “We have to be extremely selective about recommending spinal fusion if somebody only has back pain. … We certainly don't want to offer surgery when we can't be reasonably sure that we're significantly going to improve the pain, or improve the problem.”
[30:57] “We know that smoking is a big risk factor for spinal issues, both in the neck and the back. We typically do not like to even consider spinal fusion if somebody is using tobacco. But if they've used it in the past, it's likely that they get degeneration of the disk and that can lead to accelerated adjacent-level problems.”
[32:51] “I don't have a line of patients out of the front door of my office building waiting on a spinal fusion because spinal fusion does change the native anatomy. It makes a normally mobile segment stiff, so if you're fusing two vertebrae together, we're only doing that because of recalcitrant pain.”
[33:16] “The reasons that we do spinal fusion are really somewhat last resort, although in many, many people it can be a complete game changer. We've seen pro athletes return to sports, we've seen weekend athletes return to everything they want to do. With a spinal fusion a lot of times, patients assume that that type of surgery would keep them from doing many of their normal activities. But I would say that many people are able to return to everything they want to do.”
[39:12] “Innovation is really the key in surgical specialties. We really depend on innovation to get things better and in my 25 years it's been nothing short of remarkable to watch the progress that we've seen with device companies. The technology is just fascinating in the surgical field [which] is great for patients and great for us.”
