Dr. David Chang on Treatment

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ContributorDr. David Chang, M.D.Read Full Bio

Biography

Dr. David Chang is a board certified orthopedic spine surgeon who specializes in surgical treatment of spinal disorders. He has worked and studied in both coasts of the country. After graduating from Princeton University, he received his medical degree from New York University. He completed his orthopedic surgical training at NYU-Hospital for Joint Diseases. He completed an advanced fellowship in orthopedic spinal surgery with Drs. Robert Watkins and Lytton Williams. With his training under Dr. Watkins, Dr. Chang understands the complexities of sports related spinal injuries. Additionally, Dr. Chang’s interest lies in minimally invasive spinal surgery, artificial disc replacement technology and degenerative disorders of the cervical and lumbar spine. Dr. Chang is part of the Watkins Spine Group that works in association with the Marina Del Rey Hospital in the Southern California area.

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ContributorDr. David Chang, M.D.Read Full Bio

Biography

Dr. David Chang is a board certified orthopedic spine surgeon who specializes in surgical treatment of spinal disorders. He has worked and studied in both coasts of the country. After graduating from Princeton University, he received his medical degree from New York University. He completed his orthopedic surgical training at NYU-Hospital for Joint Diseases. He completed an advanced fellowship in orthopedic spinal surgery with Drs. Robert Watkins and Lytton Williams. With his training under Dr. Watkins, Dr. Chang understands the complexities of sports related spinal injuries. Additionally, Dr. Chang’s interest lies in minimally invasive spinal surgery, artificial disc replacement technology and degenerative disorders of the cervical and lumbar spine. Dr. Chang is part of the Watkins Spine Group that works in association with the Marina Del Rey Hospital in the Southern California area.

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A microdiscectomy, we're gonna break that word apart, ectomy means remove, and we're going to remove some of the disc. We're not gonna remove all of the disc material. Oftentimes a microdiscectomy is used to treat a disc herniation and we're only gonna remove a small fragment of that disc, maybe five percent of that disc material.

It's a relatively quick procedure in the world of spine surgery it's sort of the equivalent to an arthroscopic procedure although it's not technically arthroscopic. I use the term micro because we're using a very small incision and we're using a microscope. And a microdiscectomy is utilized to treat a disc herniation. And so this is a model of the spine and your back skin would be here and we're gonna make a small, two-centimeter incision for a one level procedure, slide the muscle tissue over to the side, and get access to the space where the disc herniation is and on this model, let's say it's here. This is a far lateral disc herniation and this is a unique type of disc herniation, usually their more rotated into the spinal canal region.

Once we get to this space, we're gonna have to shave a little bit of bone and that's technically called a laminotomy. We shave a little bit of the bone and we take a ligament that's overlying that area that you don't see here and we'll take that away. And once we have that opened up, then it's safer to get access to that disc herniation that's being compressed by the nerve. Sort of thinking about it, if you got a big disc herniation here, a big ball of tissue, and you got a tiny little hole and you're trying to work through that tiny little hole to pull all that material away sometimes that's hard to do and specifically when there's a pliable nerve there, a sensitive nerve, that could be traumatic to the nerve. In essence, we're making the hole bigger to make the surgery easier but also safer for the nerve that's getting compressed.

Once we take that disc material away we then just let the muscle fall back, close up the wound and it's all done. Takes maybe about an hour oftentimes we can do it as an outpatient procedure these days, come in in the morning and you can leave by the afternoon. For this type of procedure, the anesthetic time is relatively short so you don't often get a catheter into your bladder. But for longer procedures, maybe a two or three level discectomy or maybe a two or three level laminectomy you will get a catheter.

Immediately after the surgery, often patients don't complain of too much back pain but clearly sometimes we're working around the back and it can be painful. And it's hard to predict who's gonna have more back pain than the next patient who's not gonna have back pain. But generally we want patients to stand up immediately after the surgery and they're up and they're walking and if they had they red hot searing sciatica type pain, after the microdiscectomy patients are able to sort of cut through the chaff of the back pain and notice that their searing sciatica pain is gone.

You're gonna be able to go home after you meet a couple of measures. You gotta be able to walk, your pain's gotta be under control, you gotta be able to-to urinate on your own, and you gotta be able to keep food down not being nauseated and vomiting. If you meet those four end points by my standards, you can go home. Getting on to laminectomy, ectomy mean remove and we're gonna remove lamina. And the lamina is specifically this sheet of bone that blends into the spinous process. There's lamina on the right side and there's lamina on the left side. And there are different forms of laminectomy. There's partial laminectomies all the way up to total laminectomies.

And that refers to how much of this bone are you removing. And a total laminectomy we would remove all of this bone so that you could then see all of the yellow structures in this model which would be the nerves. Oftentimes when we're doing a laminectomy we might do more than just one level and oftentimes the laminectomy's gonna be performed on an maybe older patient who has multilevel degenerative problems and we're gonna do two, three, four level, so it's a longer procedure and there's more anesthetic time maybe more soreness. Oftentimes, besides a catheter in your bladder there might be some drains in your back.

Those drains are just collecting any residual fluid, maybe a little bit of blood, mostly fluid. We want to stop any bleeding accumulating causing a blood clot or hematoma on those nerves. So, you might stay in the hospital one or two nights. Again, after surgery you're gonna be walking around albeit gingerly and then as your at home all I want you to do for the first couple days is to walk. We walk you to avoid the BLT's, bending, lifting, twisting. 'Cause the more bending, lifting, twisting that you do around your back, the more you're going to stir up the pot and irritate some already irritated muscles and it's just gonna drag out the healing process if you will.

It might create even more inflammation that winds up irritating the nerve that we just wound up decompressing. So, all I want you to walk maybe three, four times a day, the extent of the walks depends on the patients exercise tolerance and conditioning. You can go up and down stairs, you can get in and out of bed a walk up and down hills is okay but generally speaking I try to have patients walk on level ground and listen to your body. If you're walking x number of feet and it's beginning to hurt you, well you want to cut that down, maybe by half initially and then just slowly build yourself back up.

We're not gonna start formal physical therapy until basically the wound and the muscles settle down and that's gonna start around four to six weeks after surgery. Once we get into physical therapy formally we're gonna talk about core stabilization strengthening again. As it relates to driving, patients often ask when can they drive and that sort of dovetails into when can they go back to work. Usually after a microdiscectomy, I think up to two weeks after the surgery you could start driving, so long as your not on any narcotics and so long as you feel reasonably comfortable to drive.

Driving will clearly put more pressure on the disc and the joints and can cause pain in the back. Usually it doesn't amount to too much but sometimes I worry about recurrent disc herniations. I think after a microdiscectomy patients go back to work anywhere from two to six weeks after surgery. It just sort of depends on what your pain level is and what your job description is. The person who has the office type job, maybe the owner of the company they're able to go back to work maybe a week or two after the surgery. The patients who have a much more physical, demanding job, labor type job, police officers, firefighters, they're not going back to work until much later after they've done the physical therapy, gotten their core strength to a level three, if not better. And sometimes that lays out to six months maybe even 12 months.


We're not gonna start physical therapy formally until maybe four to six weeks, closer to six weeks after surgery. Again, it's gonna focus on core stabilization type exercises and then you'll get into returning to work along the time line of around six weeks maybe even up to 12 weeks depending on the extent of the laminectomy, how many levels we had to do. I think that spine surgery, this day and age has really turned the corner so to speak and I think there are gonna be new technologies in the future that make spine surgery even better.

Some patients complain of back pain, we don't have a great solution for those patients and we'll be the first to admit we can't recommend surgery for that patient. But I think education is very important, I always talk about the anatomy of the spine and I think hopefully sometimes it doesn't fall on deaf ears so if a patient could bring in a caregiver when they come to their initial visits or any and all visits, I think it's always helpful to have two sets of ears hearing what I'm saying as opposed to just one set ears. I'm always available to answer questions and I think the questions only helps the patient understand what's going on with their back and ultimately is gonna help my eventual treatment maybe with surgery, maybe without surgery and their ultimate outcome. I think a better informed patient is going to be a better healing patient.

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