Deborah Doc Watson: Hi there and welcome to another edition of The Doc Watson Show. This show is designed to give you important information about health issues that impact all of us. I'm your host, Deborah Watson, and we have with us this hour Dr. Richard Fessler. He is chief of neurological surgery at the University of Chicago Medical Center and a professor of neurological surgery at the University of Chicago. We're going to be talking about some new minimally invasive spinal procedures that can be done to help us with, I would imagine, spinal injuries. Welcome to the show, Dr. Fessler. How are you today?
Dr. Richard Fessler: I'm doing great.
Deborah Doc Watson: Oh good. What is it that's going on with these new procedures? What are they?
Dr. Richard Fessler: Well, they're new procedures designed to do traditional spinal surgeries but with less invasive techniques.
Deborah Doc Watson: OK, when we talk about spinal surgeries, we're referring to what? Herniated discs?
Dr. Richard Fessler: At this point we've been developing these techniques over the last 10-15 years. We can do most spinal surgeries through minimally invasive techniques. So, we can do things like your traditional herniated disc, or we can do decompression of stenosis. When we get older, our ligaments and our bones in our spine get thicker. As they get thicker, they take up the space that is supposed to be there for our nerves. That causes pain.
Whereas we used to do traditional laminectomies, which was a very large operation where all the muscles are dissected off the spine, and then you take off the bones and the ligaments to take the pressure off the nerves. We can do that kind of an operation now through a two-centimeter incision without taking off any of the bone, essentially, and take all the pressure off the nerves. So we can do those kind of operations, we can take out many spinal tumors or even spinal cord tumors through minimally invasive techniques. And, we're working on very advanced surgeries, such as doing scoliosis, for example, through a minimally invasive technique.Deborah Doc Watson: Now, let's just start out with stenosis. All right. You mentioned what it was. How would you go in there to do that?
Dr. Richard Fessler: Well, traditionally what we would do is you would be given months of non-surgical therapy. You would be given pain medications, you would do physical therapy, you would try epidural steroid injections, chiropractic manipulations, massage, pretty much everything we can do non-surgically to see if we can relieve your pain without having to do surgery. Then if those things fail, our traditional approach would be to go to surgery and to make an incision roughly six to eight inches long and then dissect all the muscles off the spine, and then remove all the back part of the bones to give the nerves and the dura, the spinal cord, more room. And then sew everything back up.
Deborah Doc Watson: What do you do to protect the nerves?
Dr. Richard Fessler: During surgery?
Deborah Doc Watson: Well no, after you sew them up.
Dr. Richard Fessler: Your muscles are so thick that they cover it fine. There's really no major threat. The way we do it now, however, with minimally invasive technique, is instead of a six- to eight-inch incision, we would make just a two-centimeter incision, and then we would put a needle through the muscle and a series of dilators over that so it spreads your muscle fibers apart, but we never have to cut the muscle. Then when we get down to the bone, we take off just a small window of bone so we can get inside the spinal canal. Once we're in the spinal canal, we can remove the ligament and we can drill off just the inside of the bone, leaving the outside of the bone exactly as it was before we started. So we sort of just increased the size of the spinal canal on the inside where the nerves are, but we leave all the structures outside of the spine — the bones, the ligaments, the muscles — completely normal so that when we finish the operation, your anatomy is basically the same as when we started except that we took the pressure off the nerves.
Deborah Doc Watson: And you have a Band-Aid® over the two-centimeter incision.
Dr. Richard Fessler: Exactly.
Deborah Doc Watson: Maybe a couple of stitches.
Dr. Richard Fessler: Well stitches are under the skin; you never even see them. We actually glue the skin shut now, so you don't even need a Band-Aid anymore.
Deborah Doc Watson: For heaven's sake. You know I injured my back about nine years ago and I looked around for something — I ended up not having surgery, but I looked around for a different kind of surgery; I didn't want to have my back opened up. I found a doctor in California who was doing some sort of a laparoscopic surgery, which I'm assuming this one is — you're using some sort of laparoscopic equipment...
Dr. Richard Fessler: That's correct. It's an endoscope.
Deborah Doc Watson: ...to look inside. I was always under the impression, and you are certainly disabusing me of this, and that is I always thought once stenosis set in, there really wasn't much you could do about it.
Dr. Richard Fessler: No; in fact it's one of the more gratifying types of operations that we do because the results are really very good.
Deborah Doc Watson: OK, and for somebody who has been diagnosed with stenosis, you say that you can take off a little bit of the inner canal. But wouldn't it go all the way down? Or is it just a couple of little places that it's hung up?
Dr. Richard Fessler: Unless you are born with a congenitally narrow canal — which a few people are, but it's not very common — it's usually just the process of aging. It usually ends up focusing on one or two levels in the lower spine. Those are the levels that take up the majority of the forces that we generate when we stand up and walk around. So, it's usually just one or two levels where you get this.
Deborah Doc Watson: OK, so you're talking like in the L4-L5 area.
Dr. Richard Fessler: Exactly. That's the most frequent; the second most frequent is L3-L4.
Deborah Doc Watson: OK, which is lower? It's right above it, actually.
Dr. Richard Fessler: The cool thing is we could do both of those levels. Say you come in and your MRI shows that you've got lumbar stenosis at L3-L4 and at L4-L5. We can do both of those levels through that one two-centimeter incision.
Deborah Doc Watson: How long does it take for you to do this particular type of surgery?
Dr. Richard Fessler: It will take about 1.5 hours.
Deborah Doc Watson: Boy, and does the patient — is this like outpatient?
Dr. Richard Fessler: It can be. Many people who have lumbar stenosis are older, and we often encourage them to stay overnight.
Deborah Doc Watson: But they could, if they needed to, leave. Maybe you just have like a home visit or something from a nurse.
Dr. Richard Fessler: That's correct.
Deborah Doc Watson: But they could actually get up and walk.
Dr. Richard Fessler: Yes.
Deborah Doc Watson: Interesting. So, they are doing more and more of these surgeries and it sounds as if they have developed techniques for just about every type of back surgery.
Dr. Richard Fessler: Very similar technique. For example, if you came in and you had back pain and got an MRI, and it showed that you had a tumor inside your spinal canal. There are several kinds; most of the tumors that occur in or around the spinal cord are not actually in the spinal cord itself but are coming from the nerves themselves and are sitting next to the spinal cord but in the spinal canal. If you came in and you had that, that used to be a very big operation, and because we have to open the membrane that surrounds the spinal cord, you would have to lay down for a prolonged period of time after surgery for at least one day, maybe two, and then very slowly get your head elevated so that we didn't get fluid leaks and a very big operation to take it out. But we can now do that same operation through that same — well, for that kind of problem I do a three-centimeter incision rather than a two-centimeter incision.
Deborah Doc Watson: OK, so it's a little over an inch long?
Dr. Richard Fessler: We can go in and take the bone off over the tumor, take the tumor out, sew everything up. Most of those patients go home the next day.
Deborah Doc Watson: I mentioned earlier that I had a herniation. What happens when somebody has a herniation in the L4-L5 area where some of the material from inside the disc has leaked out into that area outside the annulus? Is that something that can be handled with this type of procedure?
Dr. Richard Fessler: Very usually. In fact, that was the very first procedure that we developed for these minimally invasive techniques.
Deborah Doc Watson: OK, what did you do in a case like that if you had that gelatinous material outside the disc?
Dr. Richard Fessler: Well, it turns out it's usually not gelatinous. It is when we're infants and young children, but as we get older it solidifies and becomes sort of a hard cartilage. Then at some point, something happens where we injure our back and we rip the annulus, which is the thick membrane that surrounds the disc. Part of the inner core of that harder cartilage slips out and pushes on the nerve. The way we know this happens is we get some back pain but more than that, we usually get a very distinctive leg pain called sciatica. Depending on where we get it in the leg, it tells us exactly where the herniated disc is. That pain is usually quite severe. The first thing we try and do is just treat is with some bed rest and some analgesics and a muscle relaxer to see if it will go away enough for you to continue your life without having to have surgery. If you can get by for a little while and then get into physical therapy and continue in that regard, often you can get by without surgery. But if your pain just won't go away or it is so excruciatingly severe that you can't stand it, or if it causes a neurological deficit, such as you getting weakness in you foot or numbness in your leg or something of that nature, then you may have to proceed with surgery. For the minimally invasive technique, that is absolutely an outpatient procedure. In fact, you do get up and walk out. It takes about an hour to do. It's a similar kind of technique where we do a two-centimeter incision, put a needle through the muscle and a series of dilators over that, and just take off a very small window of bone. In fact, you usually can't even see where we took the bone off on an X-ray. We take off so little. Then we just push the nerve to the side, take out that herniated fragment of disc and then just a few stitches under the skin and glue the skin shut. You're in recovery for about two hours and then you can get up and go home.
Deborah Doc Watson: You know, in a case like that, how much does something like this cost?
Dr. Richard Fessler: It will vary by the hospital. But I would expect the entire cost of something like that, including the doctor's fee, the anesthesiologist fee, the hospital fee, all of the medications, etc., I'm guessing it would be in the range of $12,000-$15,000.
Deborah Doc Watson: Oh, that's not too bad. Do insurance companies cover these types of treatments?
Dr. Richard Fessler: Yes, almost always. In fact, probably, you always want to avoid surgery if you can, but if we do a cost-effectiveness analysis, it's probably cheaper to do the surgery than to do a month of nonsurgical therapy and then have a failure and have to go have surgery on top of that, as well.
Deborah Doc Watson: How do you determine? Does a patient come in and you listen to what the patient has to say and that determines whether or not they should have the surgery?
Dr. Richard Fessler: Exactly. One of the nice things about the nervous system is the patient can usually give you their diagnosis. For example, a patient with a herniated disc at L4-L5 classically will come in and they will say, "You know, I was fine. Then I bent over and twisted to the side and suddenly I got this horrible pain in my back. It shot down my legs on the outside of my thigh and the outside of my calf then crossed over to my big toe. Now I have some numbness in that same area and I can't lift my toe up quite as well." That's an absolutely classic history for an L4-L5 disc herniation. And an L5-S1 disc herniation is described in a different location than that. Frequently, even without the benefit of an MRI, you know exactly what happened to the patient by the way they describe their pain and their weakness. We use an MRI just to confirm that, really.
Deborah Doc Watson: How long would it take for the approval to come through and get him to surgery? A couple of weeks?
Dr. Richard Fessler: It will usually take — unless it is an emergency — if a patient came in and they couldn't move their foot, for example, you might not even wait for the approval. You might just say, "This is an emergency, we've really got to do this now if you want any chance of getting that strength back in your foot." But most cases are not like that. It would take a week or two.
Deborah Doc Watson: The longer you delay, the more damage is done and the less likely you are to get a full recovery?
Dr. Richard Fessler: In general, that's correct.
Deborah Doc Watson: OK, so people who are having these problems — is this surgery practiced everywhere?
Dr. Richard Fessler: This particular technique is being done quite widely now. Because it's the first one, the oldest, it's one of the easier operations to do through a minimally invasive technique. Some of the really more advanced ones where we actually go in and take tumors out, things like that, those aren't as widely available on a minimally invasive style. But the basic ones for discs and stenosis are quite widely used now.
Deborah Doc Watson: OK. And it could be for any age?
Dr. Richard Fessler: Correct.
Deborah Doc Watson: Is it just for the elderly?
Dr. Richard Fessler: No, it could be any age. One of the great things we found with the minimally invasive technique is that where surgery in the elderly or in the obese is harder and riskier because of their risk factors, with a minimally invasive technique — because it's so much less stressful on the patient because there's no big incision, there's no big blood loss — that in fact we can operate on patients who are older and sicker and obese with no increase in risk to them, compared to a person who doesn't have those problems to worry about.
Deborah Doc Watson: What about general anesthesia? Do you put them under general anesthesia or is it just something localized?
Dr. Richard Fessler: For a disc you can do it under spinal or you can do it under general. It's really your preference. For the bigger operations that are going to take longer and are harder to do, those we still do under general.
Deborah Doc Watson: So my goodness, somebody could go in and be out of pain in a couple of hours, and get up and go on home?
Dr. Richard Fessler: Exactly. I can tell you this very accurately because my son had this operation done. He was a gymnast and he herniated a disc, and after several months and not being able to continue with his life, he decided to have it done. He had his surgery and went home a couple hours later and just sort of took it easy for a day or two and was back at school unrestricted in one week.
Deborah Doc Watson: What about physical activity such as exercising and things like that, once you've undergone this surgery? How long would you recommend somebody do a light daily routine?
Dr. Richard Fessler: I would give them about a week or two weeks of taking it relatively easy. But then at that point we begin physical therapy, start stretching their muscles out again and strengthening their muscles out. They haven't lost much because you really haven't damaged any muscles, but the muscles do tighten up. So we stretch them out and as they start feeling better, in 4 to 6 weeks they're back completely unrestricted, doing anything they want to do.
Deborah Doc Watson: Interesting. We're talking about these new minimally invasive surgical procedures that are now available and it sounds to me like all of the insurance companies are pretty much — most of them — are covering this type of treatment. I remember when I was (I was going to have it done and I ended up with traction and a few other things, and I didn't need to have the surgery and I haven't had it) so 9 years ago to here and I don't seem to have any problems. But I remember it being really expensive back then — like $28,000.
Dr. Richard Fessler: It would depend on what they were thinking of doing. Certainly there are more expensive spine operations.
Deborah Doc Watson: I was talking about the herniated L4-L5, the bulging disc. It wasn't anything I don't think unusual. I think it is pretty standard stuff — what you just explained. I would imagine as the technique becomes more widespread, like anything the price goes down.
Dr. Richard Fessler: Sure, and partially because you don't have to spend a week in the hospital.
Deborah Doc Watson: That's the beauty of that because right now, I don't know about you, but I'm not so sure I would want to stay any length of time in the hospital.
Dr. Richard Fessler: It's always best to be at home if you can.
Deborah Doc Watson: Yes, the germs at home are your germs. What other types of surgical procedures are there besides the ones we've mentioned that this would work well for?
Dr. Richard Fessler: One of the big impacts minimal invasive surgery has had has been on doing spinal fusion, because spinal fusion traditionally is a very big operation. That's really the operation that people are afraid of when they hear of spinal surgery; they think spinal fusion and people are afraid of that operation, because it was very big. Back in the 50's and 60's, the results weren't quite as good as we would have liked them to have been. We can do spinal fusion now, up to two levels, very easily using a minimally invasive technique through a three-centimeter incision, and we can do everything that needs to be done. We can take the pressure off the nerves either if there's stenosis or if there is a herniated disc, we can take care of those problems. If there is a slip called spondylolisthesis — when one vertebral body has slipped out of position in relation to the other — we can correct that. We can do the interbody fusion for fusing the vertebral body above to the vertebral body below. And for that we use cages and we use BMP because that makes the fusion occur that much more quickly. Then we can even put in the rods and the screws all through that little incision. Instead of being in the hospital a week, and having to wear a brace and then undergoing months of rehabilitation, you are usually in the hospital overnight or perhaps two nights. You don't have to wear a brace, you can begin your physical therapy in a couple weeks and by three months you can be pretty much back to normal.
Deborah Doc Watson: That's wonderful. I can't imagine anything in the medical community to my mind that has improved quite as much as this has.
Dr. Richard Fessler: We've made tremendous strides over the last 20 years. The things that have done it have been a number of things that have really helped us. One of them is the technology. We figured out how to be able to put rods and screws in through minimally invasive techniques and we've developed very reliable rod and screw systems that we can reduce the number of levels that have to be fused and have that much less impact on the patient. BMP — which is Bone Morphogenetic Protein, and causes the bones to heal together — came out several years ago. That has had a huge impact on helping your bones fuse. So our failure rate where we try to do a fusion and it doesn't work correctly has dropped to almost non-existent now, where even our best results 10 years ago was a 15% failure rate. That's almost gone now with BMP. Technology and a new biologic device have helped us a lot. Our knowledge of the anatomy and the mechanics the spine undergoes when we stand up and walk - what is our spine actually experiencing when we do that and when we carry things? Our knowledge of those processes has expanded tremendously. With that our knowledge of how we can approach the spine to fix the problems we have to fix while disturbing the normal anatomy the least has increased tremendously. When you put all these things together with well-trained physicians, the advances we've made in the last 15 years have been phenomenal.
Deborah Doc Watson: Now in the case of scoliosis, you mentioned rods and being able to do that with minimal incisions. How do you do that?
Dr. Richard Fessler: This is an area we're working on right now and we can do a moderate amount of it already. What we're doing with it, and the way we figure these techniques out, is to sit down and discuss what the problem is that we're going to try to work on. If it's curvature of the spine and exactly what kind of curvature is there, how would we fix that if we were going to do it through a traditional open operation? And then how can we do that same operation through a minimally invasive technique? So, re-secting parts of the vertebral body to straighten the spine out, to give it a natural curve that sometimes we lose with scoliosis or as we get older. What will we take away in order to give that curve back correctly, and then how do we hold it in that position through a minimally invasive technique? We will practice these techniques in the laboratory on cadavers to figure out how we can do it technically, and then what kind of devices, what kind of instrumentation do we have to invent in order to achieve that? After all of these things are in place we can start a study to try it out to see if it will work.
Deborah Doc Watson: I'm trying to think of other ways this type of technology could be used. I would imagine you are looking at monitors when you are looking at what it is that you are doing. So, developing your expertise, working from a monitor as opposed to actually looking at the person in the flesh kind of thing requires a tremendous amount of expertise?
Dr. Richard Fessler: Well, one of the things it requires is that your knowledge of anatomy has to be very good and it has to be in your brain. Because you don't get to look at the anatomy, you only get to look at little tiny piece of it. So you have to know what is next to that little tiny piece that you're looking at that you can't see. It does require that you know your anatomy very well. Then you have to practice the skills. One of the big differences between looking at the whole wound and doing an operation is that you get the advantage of three-dimensional vision. But if you're watching it on a TV monitor, it's two-dimensional and you have to get used to working in that kind of visual environment.
Deborah Doc Watson: How long does it take to develop skills to work in this environment?
Dr. Richard Fessler: There are two types of people who have to be trained. There are the people who are coming right from medical school and going into their residency training and they just learn it day in, day out over the course of a number of years. Then there are people who are already out of their training in private practice or in academic practice who want to come back and learn it in fewer than many years. Those people take about three months to get skilled in the basic procedures.
Deborah Doc Watson: OK, and are you teaching these techniques at your university?
Dr. Richard Fessler: Yes. We teach them at our university and we give courses actually all over the world to surgeons who are already practicing to help them start learning these techniques.
Deborah Doc Watson: And they're taking them back to their places of business to be able to perform it and probably teach others?
Dr. Richard Fessler: That's correct.
Deborah Doc Watson: We're going to have to go to a break right now, but when we come back we want to think if we haven't touched on something — I want to make sure we do because this is fascinating. Is there anything that we have not touched on today that you would like to share with our audience?
Dr. Richard Fessler: I think the thing for any patient who has a back problem, what they have to do to make sure that they are comfortable with their problem and their treatment is first of all to educate themselves. Get online — you can find almost anything online now — and learn about the problem you have. If you know you have a herniated disc, study about a herniated disc and what it means when you take care of it one way or another.
Also learn about the doctors you are going to see. Most of the time, you can learn a tremendous amount about them online, as well. Know who you are going to see before you go to see them. I think that's tremendously important. First of all, it will tell you if it's a doctor you want to see and secondly, it will make you comfortable when you do see them. If you have the option, that is if you're not in an emergency situation, try non-surgery first, because 95% of the time you can avoid surgery. The good news is that if you really have to have surgery, it's nothing to be afraid of anymore. There are success rates for spinal surgery that are extremely good.Deborah Doc Watson: OK, when you say success rate — what is the success rate?
Dr. Richard Fessler: It will depend on what your problem is and whether you've suffered a neurologic injury before you ever come to treatment. For something like a herniated disc for example, there is a 95% probability that you're going to have an excellent outcome. In spinal fusion the chances that you're going to have a very good outcome are in the range of 90%. Tumors, cancer — it depends on what kind of cancer it is and the stage.
Deborah Doc Watson: If we're talking about herniation or something along that line, it's really high?
Dr. Richard Fessler: It's very high.
Deborah Doc Watson: That's wonderful. I really appreciate you coming on the show today and talking about this issue. I think that people when they injure their back, I would say the majority of adults have had some sort of back injury at one point in their adult life.
Dr. Richard Fessler: We almost all do.
Deborah Doc Watson: I know I didn't want to have any back surgery, mainly because of friends I know that had back surgery and it wasn't a very good result, so I was disconcerted that I was going to need something like that, so I avoided it. But this sounds like something that would be a lot easier to handle and you're up and about within a matter of just a few weeks, back to normal.
Dr. Richard Fessler: There are two Web sites that you were asking about before where people can go to learn about all of these things. One of them is www.back.com; the other is www.spineuniverse.com. Either of these Web sites can give you phenomenal information about anything related to the back.
Deborah Doc Watson: Wonderful. Thank you so much for being on the show, Dr. Fessler.
Dr. Richard Fessler: Very nice talking with you.
Deborah Doc Watson: We've been talking to Dr. Richard Fessler. He is chief of neurological surgery at the University of Chicago Medical Center and also a professor of neurological surgery at the University of Chicago, and according to the doctor, this is the way to go, guys! If you were concerned about back surgery — maybe you've been told that you need to have your back operated on — you may want to check out these two Web sites: www.back.com (how easy is that?) and SpineUniverse.com for those of you who want to check it out…
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