Dr. Robert Watkins IV on Treatment

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ContributorDr. Robert G. Watkins IV, M.D.Read Full Bio

Biography

Robert Watkins IV, M.D., is co-director of Marina Spine Center and Chairman of the Surgery Department at Marina Del Rey Hospital. Dr. Watkins is a board-certified orthopedic spine surgeon, specializing in minimally invasive spine surgery, computer-assisted surgery, spinal-deformity treatment, and disc replacement. Dr. Watkins earned his medical degree at the University of Southern California’s Keck School of Medicine and completed his residency in orthopedic surgery at the L.A. County/USC General Hospital. He then worked as a traveling fellow in Europe, specializing in artificial-disc replacement and scoliosis surgery. Over the past decade, he has lectured on spine issues to doctors, patient groups, athletic trainers, and physical therapists; led research teams that have published studies; and taught surgeons on specialized techniques. He is the spine consultant to many Los Angeles sports teams, and has treated professional, college, and high school athletes from all over the country.

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ContributorDr. Robert G. Watkins IV, M.D.Read Full Bio

Biography

Robert Watkins IV, M.D., is co-director of Marina Spine Center and Chairman of the Surgery Department at Marina Del Rey Hospital. Dr. Watkins is a board-certified orthopedic spine surgeon, specializing in minimally invasive spine surgery, computer-assisted surgery, spinal-deformity treatment, and disc replacement. Dr. Watkins earned his medical degree at the University of Southern California’s Keck School of Medicine and completed his residency in orthopedic surgery at the L.A. County/USC General Hospital. He then worked as a traveling fellow in Europe, specializing in artificial-disc replacement and scoliosis surgery. Over the past decade, he has lectured on spine issues to doctors, patient groups, athletic trainers, and physical therapists; led research teams that have published studies; and taught surgeons on specialized techniques. He is the spine consultant to many Los Angeles sports teams, and has treated professional, college, and high school athletes from all over the country.

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Our treatment approach begins with first we need to decrease their pain and inflammation. So typically we do rest and-and oral medications, anti-inflammatories, maybe a Medrol dose pack, prednisone pack.

You gotta get rid of the inflammation so that then the muscles and the nerves can relax so then you can do physical therapy and trunk stabilization exercises and chest out posture exercises, get your muscles in a better position to work better, to take stress off the spine, off the painful disc and to keep it on the muscle. Since I learned how to do spinal injections in England, and I do them in my practice now, epidurals, nerve root blocks, facet joint injections, they're all basically anti-inflammatory steroid shots like a cortisone shot. That doesn't cure anything, it doesn't heal a disc, it doesn't heal a nerve, but it can decrease inflammation and pain to allow the natural healing process to occur and to allow somebody to get into physical therapy. And start rehabbing they're muscles with having less pain. And 70 to 80 percent of people we treat successfully non-operatively and don't need to do surgery on.

However, if somebody's still having significant pain, it's effecting their life, then we do obviously discuss surgery. And there's different surgical options. My job is to identify what's the source of the pain, what's the chance we know what's causing the pain, what's the potential surgical treatments. What are the risks of the surgery we propose, and then what's the potential success rate. In some cases, if they have a herniated disc hitting an L5 nerve and it goes right down to their big toe, that's where the L5 nerve goes, that makes my job easy.

There's a 95 percent chance we know what's causing the pain. If it's back pain its generalized back pain, well there can be five different discs or 10 different facet joints and 10 different nerves that can all be causing that back pain. Plus your SI joints and your hips and your muscles. We don't always know what's causing back pain, so the success rate of doing surgery for back pain alone may not be as good as operating on nerve pain. Because we don't know exactly which disc and which structure's causing the back pain. The second component we decide on determining surgery or not is what are the risks of the surgery. Is it a very minimally invasive small surgery like a microscopic laminotomy that takes 45 minutes to an hour. People can usually go home the same day or the next day.

That surgery is totally different than a fusion. Screws and rods and graphs, sometime we go in from the front, the side, the back; all three to correct somebody's problem. The risk of the surgery vary significantly depending on how much work we're going to do. It's really an odds game. Sometimes where somebody has a pinched nerve and the pain goes down, I can know with about a 95 percent success rate that that's causing the pain. But it's never 100 percent. We can't measure pain and the results of the surgery depend on, with what odds, how much confidence do we know what's actually causing the pain? Sometimes it's 95 percentsometimes it's 50-50!

And obviously if it's 50-50, what's causing the pain, we generally don't recommend surgery because that's not worth the risk of having the surgery. So a fusion surgery is indicated from multiple reasons, but the primary idea is that the disc and the facet joints are no longer working. They're not providing the structural stability that they should be, to protect the nerves and to decrease pain. So if the disc and the facet joints are so degenerated that they're causing pain, especially if there's instability, if you have a spondylolysis where the bones are shifting in relation to each other, a fusion can be extremely effective at stopping the motion, taking the pressure off the nerves and stopping the person's pain. When we try and accomplish a fusion, we want the two bones to fuse together.

And we want them to fuse together across the disc space or across the facet joints. So, getting a fusion to occur is physically demanding. 20, 30 years ago, the failed fusion rate was 20 to 40 percent. Nowadays, the technology has improved so much in spine surgery that our chance of being able to get a successful fusion is more like 90 to 95 percent. In order to get a fusion to occur, there's three things that you need. You need a big surface area, so we're gonna usually take the disc out and get bone to grow across the disc space, cause the disc space is a huge surface area as compared to fusing the facet joints in the back, the fusion area's not as big.


The second thing you need is you need compression. You need loading to get bone to grow. And 80 percent of the weight goes through the disc, so if you put a bone in a space under the disc space, that's where all the loading is occurring and that's where bone will grow. So you have a higher fusion rate if you're where the weight bearing is occurring. The third thing you need for a fusion is you need stability. You have to stop the motion. It's like putting a cast on the arm to stop the motion, to let the bone grow in a fracture. So, these screws are called pedicel screws and they go all the way across the vertebra, they're about four to five centimeters long, and then they're connected by rods in the back and that stops the motion across the disc and across the facet joints to allow bone to grow.

So the screws are just temporary. They're there for three to six months, they need to stop the motion so that the bone can grow. Once the bone grows, you don't need the screws anymore. We usually don't take 'em out because they're not bothering anybody so we just leave 'em in, so there's different ways we get to the disc. We either go from the front, the side or the back. And all three of those work and our results have been shown to be very similar between all three techniques. But there's risks and benefits between all three different techniques.

Going in from the front, an anterior probe which sounds kind of crazy at first to the patients we're gonna go through their stomach to get there. We don't actually go through your stomach. All your organs are contained in a sac called the peritoneum, and we actually go around that sac and so we don't see the organs and the intestines, they're all contained in a sac and we go around the left side technically. It's a pretty minimally invasive surgery cause it's not causing muscle dissection or anything else. The biggest risk of going in the front is typically that your blood vessels sit on the front of your spine. Your aorta and your inferior vena cava, the two biggest vessels in your body go down and split to go into your legs. We have a surgeon who typically works with us, a vascular surgeon who moves those out of the way to get us access to get to the disc. From a spine surgeon's perspective, going in the front is generally one of the easiest, best, safest surgeries we have.


Because once everything is moved out of the way, and retractors are put in, this is our view of the disc. We're able to take the disc out, clean all the cartilage out, all the soft tissue out, we have to remove all the soft tissue from the disc so it's just bone and bone, then we put a bony spacer in or a plastic spacer with bone in it so that then bone will grow across the disc space. If there's still disc or soft tissue, it blocks the fusion. So going in the front gives us an excellent view of the disc, an ability to clean the disc out, and biomechanically is one of the safest, easiest surgeries. The spacers we put in from the front are big and they're u-generally wedged shaped and so that opens up the front of the spine.

When people get degeneration, the disc typically collapses down. Older people get more and more bent forward in part because the disc degenerate, and they all collapse down and they lose muscle strength. But when we fuse somebody, what we don't wanna do is we don't wanna fuse 'em bent forward like this, because if we fuse this and stop the motion, these other levels have to hyper compensate to get him to stand up straight. And so that can put more stress on the other discs and may increase the chance of those degenerating. So when we fuse somebody we like to go from the front or the side to jack open the disc to get the height back so that when we fuse it may put less stress on these other levels cause they're in a better position.

Sometimes we can put screws into the spacer from the front, to provide the stability and then that's it. The screws in the front are smaller and so there's a higher chance of a non-union, of bone not actually growing there. Now if it doesn't grow, we can still go in the back and put the big screws in the back and lock it down, generally with good success rate. But it may require a second surgery, a lot of times we'll go from the front to take the disc out, put the spacer in, and then go in the back and put in the pedicel screws in the back and lock it down in the back.
Because from the front and the back at the primary surgery, is the most stable construct we have. And the chance of it fusing and getting successful bone growth is excellent.

Another way we do fusions is instead of going in the front where we have to move the vessels and everything out of the way, we can go in from the side. And the side is called an X-lift or a D-lift, we call it a lateral to go in from the side. The benefit of going in the side is, we don't have to mobilize your blood vessels out of the way so it's a safer surgery from that degree. Typically a smaller incision and a faster recovery, cause we just don't have to move everything out of the way. Going in the side, a lot of times your pelvis will block access to L5-S1 and sometimes L4-5, so we can't get to it from the side.
But for L4-5 and 3-4 and the ones above, we typically do it from the side.

The third way we do fusions is all from the back where we'll take out a facet joint and take the disc out from the back and put the spacer in from the back. That's called a T-lift, and success rate has been shown to be just as good as the other approaches, but the access to the disc is not as good from the back because the nerves are in the way. So we work through a smaller hole, and the spacers are not as big. So it's a good surgery in certain situations, but in our practice we like to go from the front or the side typically more often, because we can put in bigger spacers and get better correction of deformities.

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