I'm Dr. Robert Watkins IV, I went to Vanderbilt for college, came back to Los Angeles, went to USC for medical school and orthopedic residency, I spent nine years at USC at county hospital. And then I spent a year in England training and doing spine surgery in England, a fellowship in spinal deformity, big scoliosis and corrections in England, which was a wonderful experience.
Back pain is a huge problem in America. Everybody has back pain at some point in their lives. Usually it goes away after a week or two, but sometimes it continues to happen and occurs more and more often and really is debilitating, it affects every aspect of a person's life. Part of the fundamental problem is that we're all so healthy now. Human life expectancy used to be age 50. Nowadays we're so healthy that our heart and our lungs last longer, we live until we're 80,90, 100 years old which is great. The problem is our back and our joints start fallin' apart around age 30. So it's this race between how to keep our joints and our back healthy and non-painful while we're living so much longer.
Part of the fundamental problem of the spine is there's so many moveable parts. In your neck you have seven moveable discs, thoracic spine 12, lumbar spine five, and then you have facet joints, for each disc in the front, two facet joints in the back. The spine is a very complex structure, you can see this is a lumbar spine, between here and here this is a real life size model. The disc is a source of pain. The disc is a woven basket that provides stability between the bone so every time you move and bend and twist, motion goes through the disc. 80 percent of all your weight goes through the disc. So, when people get back pain, a flare up of back pain, and they say oh I threw my back out, it's usually because they get a tear in the disc and it hurts just like tearing a muscle or a ligament in your body and then it actually releases acidic chemicals that irritate the nerves. Then you can get sciatica, and get nerve pain. The muscles will clamp down to stop any motion, then you get muscle spasms and everything locks down. But for each disc in the front, you also have two facet joints in the back. And that's where the motion occurs in the back, and this is a joint just like a knee joint or a finger joint, it's where motion occurs, it's innervated.
So if you get an injury to the joint, it'll hurt just like you sprained your knee. You sprained one of these joints and then on top of that you have nerves that come out between, these yellow tube structures of the nerves coming out. So you can injure a disc that then can irritate the nerve, the facet joint can get overgrown and then pinch the nerve and then you can get nerve pain. So between here and here in the human body, you have about 20 structures that all can be a source of significant pain. One of the fundamental parts of my job as a spine surgeon is to identify what exactly is the source of pain. Especially if we're going to do surgery, the outcome of the surgery depends on our ability to know what's causing the pain.
When a patient first comes to see me in the office, the first thing we do is take a history. I talk to the person and find out what's their primary complaint, what's bothering them and then how is it affecting their life, what do they want to be able to do that they can't do because of the pain. And then we also get some signs as to they get more pain standing, or sitting, or walking, what provokes the pain gives us some ideas to what is causing the pain. When you flex forward and rotate, you load the discs more, and so that can provoke disc pain. When you lean back, you load the facet joint, so that may provoke facet joint pain more, or a stress fracture in the back if you lean back it can provoke pain from stress fractures which a lot of young athletes get. If they get pain while they sit and it goes down the leg, it's more typical for nerve pain. The next thing we do is the physical exam, it helps us determine what is their deficit, do they have a neurologic deficit, do they have weakness or numbness. It also tells us do they have nerve tension.
So diagnostic studies in our business are very important because we have to identify what's the source of the pain? The first study we get is a plain x-ray, and we shoot an A/P lateral and flexion extension typically. So plain X-rays tell us about the bone anatomy, the alignment, is there any collapse of the disc spaces, is there any shifting of the bones in relation to each other. When you get degeneration, it can develop instability 'cause the disc and the joints aren't holding the bones in proper alignment which can pinch the nerves more. We shoot flexion/extension x-rays to see if there's any dynamic motion occurring in between the segments. When you get significant degeneration, you get sloppiness of the disc which can allow the bones to shift in relation to each other and that tells us a lot about what's the underlying problem and is it potentially the source of pain.
An MRI's the most common test ordered all over the world. The MRI is a non-invasive test, you get no radiation from an MRI, or extremely little and it moves around your body and it shows the doctor what is going on inside your body. It's an amazing test, probably the greatest invention in the past 100 years. An MRI shows the soft tissue. So an MRI shows us the disc is soft tissue, it shows us the joints, because the joints have a soft tissue capsule, we can see is it overgrown and hitting a nerve. And the MRI shows us the nerves which are soft tissue. So we can actually see the nerves going through the spinal canal and we can see is there any pressure on the nerve, is there anything pinching the nerve or squeezing it.
A bone scan is a test where they inject a marker into your blood that marks osteoblasts which are bone making cells. And so if you have a crack in the bone or an area of increased stress on the bones from a degenerated joint or a degenerated disc that then is loading the bones. The bone scan will light up this area with increased metabolic activity because the body is trying to heal that area. So the bone scan is a really good screening test to see if you have anything going on in any joint or bone in your body.
From your spine, to your hips to your SI joint, any joint in the body can light up on a bone scan if there's pathology in it.
The EMG or nerve conduction study is a nerve test where they put little needles in your legs or your arms to test the muscles. And it tests the electric signal across the muscles and it tells us what’s the status of the nerves. Are the nerves sending an electric signal down to the muscle and firing the muscle. Sometimes the test can be a bit painful, but it really depends on whose doing the test, and but the test can be extremely helpful to determine which nerve is being effected that's going from your spine down into your leg and it can also tell us do you have peripheral neuropathy. Which is dysfunction of the nerves in your legs themselves that has nothing to do with your back.
The number one thing we're treating is pain. And we can't measure pain, so we get different diagnostic studies such as the X-rays, the MRI, the CT scan, the nerve test, and none of those tests are 100 percent, but they overlap. The more those tests overlap and point to one source of pain, the m-higher the odds are that we know what the source of the pain is and the better the chance the surgery will help that pain. 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.
Recovery after fusion is a big deal. The benefits of us putting graphs into the disc and screws in the back is that it's so stable it's pretty hard to mess up the surgery. And we can mobilize people very quickly. We usually get 'em up the same day of the surgery and walk right away. People typically stay in the hospital for two or three nights. They can go home, in general, when three things occur. When they're passing gas so we know that their intestines are awake, when they're ambulating independently, they can get in and out of bed and walk so when they go home they can go to the bathroom on their own and get up and move. And the third part is, their pain has to be controlled with oral medications.
I tell patients all the time, it's gonna hurt when they get in and out of bed. When you change position to get in and out of bed, it hurts. And people don't need to be too paranoid that they think they may be messing up the surgery, cause it hurts when they get in and out of bed. They're not messing up the surgery, the screws and the graphs are so stable, you're not gonna mess up the surgery getting in and out of bed. It's gonna hurt when you do that, and that's normal, that's part of the surgical pain. Once you get up and move and you walk around, and your body loosens up, you'll feel better overall. I see people back two weeks after the surgery typically. And I would say at least 50 percent of people are doing better than they thought. They're actually mobilizing pretty well, the hard part about our job is, we can never predict who are gonna be the 20 percent of people who aren't doing well.
And who are gonna take twice as long to heal. Recovery from a fusion obviously varies person to person, but in general, most people's surgical pain lasts for six to eight weeks. WE start physical therapy around eight to 10 weeks after a fusion. So the first eight to 10 weeks, we just want 'em to walk. Just get out and move and walk around and don't stress your back too hard. We generally start physical therapy when we think the muscle pain has settled down, and their muscles are starting to fire to where they can protect that segment and work properly. Typically, for the fusion to occur takes three to six months, so we don't wanna start the activity too early before we think we have some bone growth in there to provide some stability.
So we start physical therapy around eight to ten weeks, we generally want the patient to go two to three times a week for basically 12 weeks. And that's about the average, so it's about three months altogether. We have a trunk stabilization program, you start at level one as the most basic, level five is the max; professional athlete can't go back to their sports until they're level five. Most people, I want them to get to level three. If they get to level three, we know they have a good enough core strength and it's firing properly to protect the other segments that if they reach level three and they're six months after a fusion, we generally will let them go back to almost any activity.
I would say full recovery from a fusion, the bone growth takes three to six months typically, but most recovery’s really a year. And part of that is, most people have had pain for two to three years before the surgery so none of the muscles are working properly. They have neural muscular dysfunction, they're guarding they're protecting. Mentally they have this block that doesn’t allow them to move in certain situations so they don't provoke the pain. It takes three to six months for the bone to grow, the fusion to get solid, it takes another six months to retrain all those muscles and the neural-muscular connection to not guard and not protect, but to work properly. So really a fusion takes a year to sometimes even two years to recovery from, because a lot of it is the preexisting pathology before the surgery.
One of the great things about a fusion is it can immobilize a segment and stop the pain from that segment. But, the downside is, it can put more stress on the next segment. Cause if this doesn't move, well then the stress and the motion has to occur from the next level. And it can accelerate the normal wear and tear that's already occurring at that next level. So people can develop pathology and degeneration at the level above a fusion, and that can happen anywhere from six months to 20 years after a fusion, at any time. There is no way to stop it from happening, per say. Some of the things we do surgically is we really try and recreate the normal curvature in the lordosis when we do the fusion to put less stress on these other levels.
Keep cardiovascular exercise as part of their routine three to five times a week, get out and exercise, mobilize their muscles, circulate their blood has been shown to decrease back pain in general. And then the third thing is doing trunk stabilization exercises. Having a normal program, 15 minutes every day for the rest of their life, do core strengthening and exercises to wake those muscles up and to keep them firing to take stress off the other joints and discs and to keep it on the muscles. The mental aspect to pain is one of the most challenging and interesting aspects of my job. I see people all the time that have an anatomic source of pain but then also the mental and emotional component of pain is just as overwhelming. And it's a chicken or the egg, they both effect each other. You have pain, you get tense, you get mad at your spouse, they get mad, it makes the pain worse and it goes back and forth and it's a very difficult thing to deal with. Some people have more mental and emotional pain that they store in their spine and working out where does each person lay on this schedule is something I work with patients to understand. Especially before we do surgery. I've had some patients I've-we've talked about that with, they've done some work on it and come back to me and said I was able to let go a lot of the pain I had cause a lot of it was mental and emotional. And thank you for not operating on me.
So, we may be able to address the physical pain by doing physical therapy, getting the muscle strong, doing surgery to address the physical component, but the mental and emotional part is just as important. Patients wanna know that one, they're not alone. That they're not making up this pain, that they're not just being a wimp and they need to just get over it and live their life. I see so many people every day suffering with back pain and it effecting their life in every way.
Pain is one of the most-least understood functions of the human body. We can't measure pain and we don't always know why it occurs and what the provocation is, and just as mysterious as sex. How sex works and how the blood flow happens, and is it mental or physical or a combination of both is just as mysterious. And then when pain and sex go together, it's a very difficult problem that we deal with, that patients deal with, that there is no easy answer to. Cause if you're in pain, it'll affect your ability to have sex. The biologic function, much less the mental component and then you're in a relationship with somebody else, you're in pain all day long and you feel bad about it. They feel bad about it, they wanna help you, or they think you're being a wimp and you think your being a wimp. All the layers of complexity that go along with being in pain and having somebody help-have to take care of you. You don't want 'em to help take care of you anymore, and then putting sex into that relationship is so complicated that it adversely affects both relationships. And so the most important component is patients being able to talk to their doctor about it and it being accepted and it's not your fault. This is happening to most everybody who has back pain. And to be able to deal with it openly, and to acknowledge what things cause pain and what don’t.
When a patient comes to see me in the office, I really encourage them to bring a list of questions they have, bring a significant other, a caregiver with them, somebody else who can hear what I had to say and help interpret what it was after the fact. I know when patients first meet with a doctor, we overwhelm them with a lot of information, especially with spines. There’s a lot going on, there's a lot to know, a lot of facts. And we try and keep it simple and explanatory, but it's just a lot to comprehend. And, so having another set of eyes and ears there with you that can hear it and take it down, take notes. I give my email to every patient I see who then email me with follow up questions cause I know once I leave the room they think of five other questions that just finally popped into their head. Caregivers are vitally important, especially after the surgery.
And going home and being at home by yourself, no matter what surgery you undergo, is very difficult, especially a spine surgery. So having somebody there who can just help with very basic things, food and cleaning and helping with your pain medications is really important. We don't let anybody go home until they can get up and move and get to the bathroom on their own, but having somebody there to help support you at least for the first couple weeks is extremely important.
One of the greatest things I learned from taking care of professional athletes, one of the keys to taking care of them is treating each person as a person, and don't get too caught up in the hoopla and everything else, but this is a patient of yours and do what's best for them.
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