Sunday, August 26, 2012


Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

I hate to be the bearer of bad news but realistically, you need to know this: There is no cure for osteoarthritis of the spine, the most common cause of chronic low back pain.  Your lumbar spine is a weight bearing structure, similar to your knees, your hips, and ankles.  (Reminder, this discussion has very little to do with your neck or thoracic spine; they have different purposes.)

There are some blogs and websites that insist you can "rebuild" your back.  That's not possible for people with osteoarthritis.  People with sprains and strains that have not progressed to osteoarthritis can "rebuild" or strengthen their back.  There are ways of decreasing pain and cutting down on re-injuries, too.  However, the only person who could "rebuild" an osteoarthritic back would be a surgeon, and he is only resurfacing or remodeling.  The structure is what it is.

Osteoarthritis is the chronic degeneration of the structures that make up the spinal column: mainly the discs, the cartilage, and the ligaments.  The discs dehydrate and collapse; the cartilage cracks and breaks down; the ligaments become stiff and less flexible.  Even without external factors caused by overwork, this process is related to aging.  Until someone comes up with a fool proof method of reversing aging, osteoarthritis will not be reversible.

I'll use the knee as an example of a weight bearing joint.  The same things I will mention here apply to the hips, lower back, and ankles.

There aren't many people claiming they can rebuild your knees, although doing so may be easier for the surgeons than rebuilding your back.  A serious knee injury, say a torn ACL (anterior cruciate ligament), leads invariably to osteoarthritis of the knee.  This is true whether the ACL is reconstructed or not.  The osteoarthritis (degeneration of the cartilage, collapse of the joint space, loss of flexibility of the ligaments) is inevitable.  The time it takes to degenerate can be affected by life style, however.  Serious injury makes the joint too mobile, allowing structures to move too far stressing other structures, leading to premature aging.

At age 19, I had my right knee severely damaged playing spring football in college.  I tore the MCL (medial collateral ligament), the medial meniscus (cartilage), and the ACL.  In 1967, they didn't surgically repair ACLs like they do today.  They did remove the damaged cartilage, however.  MCLs heal on their own; they have good blood supply.  ACLs do not heal, having poor blood supply.  The orthopedic surgeon told me that I didn't need an ACL.  As long as I kept my quadriceps muscles strong, he said, my knee would function normally.  I believed him and I spent a lot of time exercising my legs.  I had some problems, but overall, my knee has served me well.  It has been essentially pain free for 45 years.  I played soccer until I was 45.  At 65, I continue to run 5-8 miles twice a week.  However, if you x-ray my knee, it looks like it should hurt a lot.  I have bone spurs, a flattened joint, and nearly bone on bone collapse of the joint space -- a typical severe osteoarthritis x-ray.

Exercise of joints with osteoarthritis is important.  This is true for backs, hips, knees, and ankles.  Motion is the lotion, as one neurosurgeon I met told me.  Under-exercise and over-exercise can lead to more degeneration and pain.  When an ACL is repaired, the athlete can continue to exercise.  His knee joint will still develop osteoarthritis, but more slowly than if he stopped exercising.  When you suffer a back injury, motion is an important part of recovering, and keeping the muscles strong in your abdomen and back help protect you from further injury.  Gradual onset of osteoarthritis is almost inevitable with a severe injury, but moderate exercise delays the progression.  So, even if osteoarthritis can't be cured, it can be delayed and the pain minimized.  Being active is important.

In addition to being active, decreasing the load your lower spine has to bear also slows the progression of osteoarthritis.  So if you are overweight, losing weight helps your back.  Avoid lifting very heavy objects.

Osteoarthritis is a chronic, progressive medical condition with no cure.  That does not mean having this disease is a death sentence.  Many people live very well with it.  It's not reversible, but you can slow its progression if you remain active.  To minimize discomfort lose weight and don't overdo it. 

Sunday, August 19, 2012

Red Flag

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Last week, I sent the following letter to the editor of the Florida Times Union, Jacksonville's newspaper.  It appeared in the paper August 22, 2012.  Although it makes a case for having health insurance, its most important aspect in this blog is to point out another Red Flag, one I had not foreseen, have never seen before, or put in my book.  I don't have a preference as to how everyone gets health care, just that they get it.  (Romney's plan in Massachusetts or Obama's plan for the country aren't that different, and there may be others that work better.) There is no reason for anyone to die of a preventable or treatable disease in the United States.  I admit, none of us are going to live forever, so the care of terminally ill people needs to be addressed.  Those expenses shouldn't bankrupt the country, but preventive care, vaccines, and treatment for significant illnesses and trauma need to be taken care of in order to prevent the premature death of individuals.

Letter to the editor, Florida Times Union:

Dear Sir;

The following is a case for the Affordable Health Care Act.

I am a physician.  I work in an urgent care in Jacksonville part-time.  A patient came in complaining of back pain for a week after working on a friend’s car.  This 48 year old gentleman is normally an auto mechanic, but has been out of work and is uninsured.  He paid the urgent care fees out of his pocket – about $85 for the visit.

His story was a little unusual in that his pain was so bad that his legs buckled three times in the previous week and he had fallen to the ground.  I am usually very skeptical of patients complaining of back pain because of previous patients who have been drug seeking.  However, his pain was new, not chronic.  As part of my back pain exam, I look for aortic aneurysms by checking for aortic and femoral pulses.  He had neither.  Neither did he have pulses in any other place I checked on his legs or feet.

I did not know the exact source of his back pain, but there was a good chance he had obstructed his aorta, which can be fatal.  The patient needed an MRI or other imaging to determine why he had no pulses.  I sent him to an ER in Jacksonville and I called the physician there to tell him he was coming.  They did the MRI and determined he had a large blood clot in his aorta.  Then they told the patient he needed surgery and discharged him.  When he balked at leaving the hospital with a potentially fatal medical problem, someone on staff allegedly told him, ‘You would not put a transmission in someone’s car unless he paid you, would you?’

Fortunately, the patient’s family took him directly to Shands Hospital, where he underwent a 7 hour surgery and had the blood clot removed.  His prognosis is good.  He will not be paralyzed; his kidneys continue to function, and he will eventually return to being a productive member of society.

A 48 year old man should not die of a surgically treatable medical problem.  As a tax-payer, I am going to pay several times for his care, because it took two ER visits (they sent him to the fast track and tried to discharge him with pain medication when he first went to the hospital) and two hospital admissions, emergency surgery, and recovery.  If he had become paralyzed or his kidneys had shut down, tax-payers would be supporting him for the rest of his life.  Of course, it would have been cheaper if he had had the common sense to just die.

Under the Affordable Health Care Act, this man would have had insurance and probably a primary care physician.  He would not have been discharged untreated.  His surgery might have been unnecessary or if not unnecessary, maybe elective and not emergent.  This will be a more efficient system and overall will cost the taxpayer less.  Also it tells the medical providers that the days of unlimited greed are over, which will also lower costs.  Maybe if we get rid of some hospital, insurance, and HMO CEOS who make multiple millions of dollars while auto mechanics die, people’s perspective on medical care will change.  We all are entitled to Life, Liberty, and the Pursuit of Happiness.  I think Life includes treatment for medical problems.

Update: September 4, 2012

After several replies on the Times-Union web site suggested that the patient was at fault for not having health insurance, I responded with this:

I guess I didn’t get my point across. Preventive medicine saves a lot of money. Going to the ER to have delayed definitive care when you could have prevented the problem (in this case a hypercoagulable state that led to the blood cot – which still needs to be addressed and treated in this patient) is way too expensive. This whole problem might have been prevented by taking an aspirin per day, pennies versus thousands of dollars. With 50 million people without health insurance and avoiding doctor visits and preventive care, you end up with millions of diabetics, hypertensives, and others who then go on to have very expensive strokes, heart attacks, cancer, etc. Taxpayers support all these people through Medicare, SSI, Medicaid, and other programs. And people with health insurance pay much higher premiums to cover losses generated by the uninsured. These problems are much easier and less expensive to treat early rather than later. When 1/6th of the nation is without health care, and people die from preventable or treatable diseases, something is out of whack. This is not a third world country; in fact it is the richest country in the world.

I don't have a preference as to how everyone gets health care, just that they get it and preferably before it is the expensive, last ditch version. (Romney's plan in Massachusetts or Obama's plan for the country aren't that different, and there may be other plans that work better and less expensively.) There is no reason for anyone to die of a preventable or treatable disease in the United States. I admit none of us are going to live forever so the care of terminally ill people needs to be addressed. Those expenses should not be allowed to bankrupt the country. Preventive care, vaccines, and treatment for significant illnesses and trauma are relatively inexpensive and need to be taken care of in order to prevent the premature death of individuals.

Who among you would condemn a teenager to death because he chose to ride a motorcycle, or chose to ride a bicycle without a helmet? Didn't wear her seat belt? An unemployed adult who chooses to feed his family or pay rent instead of buy health insurance? It happens too often. People sometimes make bad choices or have bad gambles forced upon them by circumstances beyond their control.

We have the best medicine in the world, and the worst delivery system.

Monday, August 13, 2012


Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

I've got to stop reading the newspaper.  I made the mistake of taking Dr. Donohue's advice about a month ago.  A reader wrote in about his gaining a pot belly that only showed when he stood, not when he was supine, even though he was about the correct weight.  Dr. Donohue reminded the reader that in addition to being the correct weight, he needed strong abdominal muscle to hold his intestines in place and that crunches wold be a good way of strengthening his abdominal muscles.

So, since I have a bit of a bulge also, I thought that was good advice.  I am about the correct weight,(BMI 24; 5'10", 165#) although I weigh about 10 pounds more than I did in high school 50 years ago.  In addition, I have had several abdominal surgeries that weakened the muscles.  Although I run twice a week, I don't do a specific exercise for my abdominal muscles.

Crunches are not a good idea!  Specifically, they are a bad for people with back pain.  I knew that.  I even wrote that in the book.  I tell patients the same thing in the office.  As I point out in one of the appendices, I have several herniated disks and lumbar stenosis.  I have undergone two back surgeries.  Well, my stomach is slightly stronger.  Still no six pack, though.  But my back is way worse.

Every time you do a crunch, or a partial or complete sit-up, you tighten all your abdominal muscles and back muscles.  This has the effect of pulling your head toward your feet, squeezing vertebrae closer together.  The end result is your discs bulge more and any stenosis is worse.

This episode will take about two weeks to blow over.  Relative rest, some Aleve, some ice, and some time and I'll be back to my normal self.  Guess I'll have to cut down on the calories and/or rely more on the Side-bridge, Cat-camel, or Bird-dog exercises to strengthen my abdominals.  You should, too, if you have lower back pain.

Monday, August 6, 2012

Minimally Invasive Back Surgery

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

There are three levels of surgery, for those few patients who need it.   

Open surgery is the old fashioned kind where the surgeon opens up a surgical field big enough to use carpentry tools and play golf: hammer, saw, wedge and putter.  This was the way all surgeries were done until the arthroscope and laparoscope were invented.  I have  two 4 inch scars on my right knee from a knee exploration done in 1969.  The surgeon could have driven a BMW through the holes he made, and he still missed the fact that I had torn loose my ACL.  Didn't matter at the time, though, because they didn't repair ACLs back then.  The recovery time for open surgery is the longest because many supporting structures are cut (damaged by the surgeon) and they have to heal.

Microsurgery followed the advent of the arthroscope and operating microscope.  The tools are smaller, so the incisions are smaller: 1-2 inches instead of 4-6 inches.  Because the incision is smaller, fewer supporting structures (ligaments, muscle, and bone) are damaged and healing takes less time.  The trade-offs include the loss of visual field for the surgeon, so finding and getting to the part needing repair takes longer.  Also the tools are microscopic, so it may take a long time to remove damaged structures one small bite at a time.  This means more time under anesthesia, something some patients can not tolerate.

Minimally invasive surgery leaves the smallest scars and recovery time is the shortest because fewer tissues are damaged.  The surgeon makes a one inch incision and then pushes a solid instrument into the hole.  Over this instrument he passes larger and larger dilators until he has a tunnel through which his instruments fit.  Instead of cutting structures, he is pushing them to one side.  Healing time for stretched muscles is a lot shorter than for cut muscles.  Time under anesthesia goes up, again, because of the smaller visual field and smaller instruments.

Some surgeons will tell you they can only do one level of minimally invasive surgery at a time and that may be true, depending upon what they are fixing.  Sometimes they just want to do more than one procedure.  They get paid for each one.  I had spinal stenosis on both sides at three levels in my lumbar spine.  One physician I know would have required me to have 3-6 separate procedures.  The man who actually did the surgery did all six locations in one operation.  I was really uncomfortable for about a week, but I only had to undergo anesthesia and recovery one time.

Think about your choices and get the surgeon to explain them thoroughly if you need surgery.