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CINN has specialists available to evaluate job requirements and susceptibility to back injuries. If you are interested in this service, please contact Lisa Dombro at ldombro@cinn.org
Editor’s MessageThe Discussant is a new way of communicating information about the CINN Work Injury Program. Each issue will be published under the guidance of a guest physician editor. As Medical Director of the CINN Work Injury Program, I have the distinct honor of being editor for this exciting inaugural issue. In this issue of The Discussant comes the excitement of FDA approval of the first artificial disc used to treat lumbar degenerative disc disease. Many believe the artificial disc will be to spine treatment what the artificial joint has become to hip and knee replacement. We are also highlighting the physiatric approach to treating lower back pain. Philosophically different from other physician’s approach to pain management, physiatrists begin with an evaluation to identify the patient’s main pain generator. Rather than simply treating the pain, which doesn’t solve the underlying problem, physiatrists get to the root of the problem and utilize a combination of appropriate non-invasive and minimally invasive procedures to solve it. Given the specificity in our approach, we believe patients recover faster and are able to expeditiously return to work. On behalf of my colleagues, we welcome the opportunity to work closely with you in caring for your patients and employees, as we assure you that they will be treated with the latest advances in non-operative and surgical spine care. Daniel
Hurley, M.D. |
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CINN treats more patients with brain and spine disorders than any other neurosurgical practice in Chicagoland
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A New Alternative to Spinal Fusion: Charité Artificial Disc
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On October 26, 2004, the Food and Drug Administration (FDA) made artificial discs available in the United States by approving the Charité Artificial Disc for the treatment of low back pain from degenerative disc disease. The Charité disc is the most thoroughly tested total disc replacement in the world.
Degenerative disc disease is a natural occurrence experienced, to a degree, by all adults, as they grow older. In fact, 80-90% of the population in the United States will suffer at least one debilitating episode of back pain in their lifetime. Fortunately, 90% of these sufferers will recover within 6 weeks. Surgical intervention is only offered to the small number of patients who fail to respond to conservative therapies. Studies have shown that spinal fusion surgery, accepted as the gold standard surgical treatment, reduces a patient’s pain 60-70% of the time. But spinal fusion takes a long time for healing and recuperation and may cause adverse effects on adjacent levels. It is because of these circumstances that experts predict that disc arthroplasty has the potential to become to spine treatment, what the artificial joint has become to hip and knee replacement.
Worldwide
experience with the Charité disc, commencing in 1987, now comprises
more than 7,500 cases implanted in some 30 countries throughout Europe,
Asia, Canada, Australia, Africa, and Latin America. European outcomes
data are compelling. Studies reflecting five and ten year follow up periods
report good or excellent clinical outcome in 84.8% and 90% of the study
populations, respectively.
The Charité artificial disc, comprised of two metallic endplates and an unconstrained polyethylene core, is designed to help align the spine and preserve motion. The free-floating design allows the core to move dynamically within the disc space during normal spinal motion, moving posteriorly in flexion and anteriorly in lumbar extension. This movement, unlike traditional fusion surgery, reduces stresses and motion at adjacent levels that may lead to adjacent level disc disease.
Results from the pivotal study
A Targeted Approach to Treating Back Pain
The physiatric approach to low back pain is a very simple but comprehensive one. The first principle is to attempt to identify the main pain generatorMany times this is difficult due to the ambiguity of symptoms that some people experience. To this end, physiatrists perform a very careful history and physical exam, prudently use imaging studies (such as MRI, X-rays), and perform diagnostic spinal injections under fluoroscopic guidance. Return to function, prevention of re-injury, management of pain, and patient education are keys to the approach.
The
main types of pain generators that are encountered, and can be treated
effectively with minimally invasive techniques are the nerve root, annulus
fibrosis of the intervertebral disc, the zygopophyseal joints and the
sacroiliac joint. Physical, occupational and other manual therapies are
nearly always the underlying mainstays of treatment.
The most common injection that is performed is an epidural steroid injection. It is most commonly used for either nerve root generated pain from a herniated disc (pain that starts in the low back, goes down the leg below the knee called radiculopathy) or discogenic pain (pain from the outer portion of the disc called the annulus fibrosis). Oral medications and/or epidural steroid injections can be used to treat this pain.
For a persistent herniated disc causing a pinched nerve that does not respond to epidural steroid injections, new procedures called percutaneous disc decompressions may shrink the herniated disc and help alleviate pain without actual surgery.
Pain that arises from the disc itself is often difficult to diagnose and treat. Usually these patients complain of pain that is worse with sitting, and is improved with bending backwards. A discogram is a procedure that attempts to verify exactly which disc is painful by instilling dye into the disc. This allows the doctor to view the disc under x-ray and analyze its structure, as well as determine if the disc is sensitive to the increased pressure from the dye. Treatment consists of epidural steroid injections, preferably given via the transforaminal route, intra-discal injections or referral on to surgery.
The facet, or zygopophyseal joints, has also been proven to be a pain generator in the low back. When these joints are dysfunctional, patients typically complain of pain located in the low back that does not radiate below the knee and which is worse at the end of the day and improves with sitting. Injections of steroid and numbing medicine directly into the joints may help relieve the pain. Another alternative is to perform an anesthetic block to the nerves that supply sensation to the joint. If either the facet joint injection or the medial branch block gives excellent relief but is short-lived, radiofrequency neurotomy, a procedure using heat to cauterize the nerves that supply the facet joints, is an option to induce long-term relief.
The sacroiliac joint is often cited as a pain generator in the low back. Patients have often experienced a fall landing on the hip or tailbone areas as the instigating event. These patients typically complain of low back pain in the upper buttock and may be worse on one side than the other. Also, their pain is increased with walking and does not go below the knee. Of note, some patients who have undergone a fusion in the lumbar spine are prone to this disorder. Injections directly into the sacroiliac joint can be helpful for this problem.