Editor’s Message CINN Physiatry Group Advances in Spine Fusion Therapy the Right Way Upcoming Events

Physiatrists Thomas M. Boetel, D.O. Brian Couri, M.D. Lawrence Frank, M.D. Daniel Hurley, M.D. Viola Molina, M.D. Howard Robinson, M.D. Christine Villoch, M.D. Surgeons Thomas Brown, M.D. Kenneth Heiferman, M.D. Thomas Hurley, M.D. Dean Karahalios, M.D. Martin G. Luken, III, M.D. Noam Stadlan, M.D.

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 Message This issue of The Discussant, CINN’s electronic newsletter focusing on issues important to the work injury community, gives testament to our unwavering and sincere interest in providing patients with leading edge technologies and treatments. We will review the use of biologics to enhance bone healing after spinal fusion surgery. These new products eliminate the need of harvesting bone graft from the iliac crest (hip bone). This advancement in spine surgery is not inconsequential, as studies have shown that the harvesting of iliac crest causes longer surgeries, produces greater blood loss, and often yields chronic hip pain at the donor site. This issue also highlights the importance of properly directed physical therapy in the success of treating back pain patients non-operatively. CINN’s fellowship-trained physiatry staff specializes in all forms of non-operative care for back pain, including the proper prescription and management of optimal physical and occupational therapy. Through clinical advancement and proper focus, CINN is paving the way for superior patient care in Chicagoland and Northwest Indiana. We are committed to your patient’s health and your reputation as a partner in this care. On behalf of my colleagues, I assure you that our interests are in the highest regard of the patient’s care and progress. Dean G. Karahalios, M.D. Guest Editor

Dean G. Karahalios, M.D. Neurosurgeon Dean G. Karahalios, M.D., a board-certified neurosurgeon, is well versed in treating the full spectrum of neurological disorders. He is fellowship-trained in spine and a leading authority on the treatment of patients with complex spinal disorders. Dr. Karahalios is particularly well known for his use of implants, fusion systems, instrumentation, and innovative complex spine techniques to treat patients with degenerative problems, and traumatic injuries to the spine.

CINN Physiatry Group At A Glance Physiatrists are physicians concerned and trained in the diagnosis, evaluation and management of persons with physical disability. Physiatrists treat a wide-range of problems from back and neck pain to shoulder injuries to spinal cord injury. How do Physiatrists Treat Back Pain? • Exercise prescription • Referral and management of physical therapy and occupational therapy • Medication management • Activity recommendations • Full range of spinal injections • Radiofrequency neurotomy Our qualifications • 8 board-certified & fellowship-trained in spine physicians • Locations: 5 throughout Chicagoland • Patients Visits Annually: 12,000 • EMGs annually: 850 • Injections annually: 4,100 CINN PHYSIATRY SITES

Advances in Spine Fusion

It is estimated that more than 500,000 bone-grafting procedures are performed annually in the United States with approximately half of these procedures related to spine fusion. The success of spine fusion depends on the creation of long-term spinal stability. Whereas spinal instrumentation devices may provide temporary support, a solid bony union must be achieved to provide permanent stability. Surgeons harvest bone from the iliac crest (hip bone) as an adjunct to spinal instrumentation to aid in the fusion process.

Advancements in bone graft substitutes and bone growth extenders could make the need for harvesting iliac crest autograft obsolete in spine fusion cases. Studies show that the harvesting of iliac crest autograft causes longer surgeries, produces greater blood loss, and often yields chronic hip pain at the donor site. Because of these drawbacks, members of the CINN medical group have been researching bone graft technologies since 1998.

Currently, iliac crest cancellous bone graft is considered the “gold standard” in grafting material for fusion mass formation in the spine, especially in the lumbar region. However, there are disadvantages to using this material. First, there is a limited supply of the autograft. Multilevel fusions require substantial amounts of bone graft, which the iliac crest harvest sites may not be able to accommodate. Second, patients who have had previous graft harvest procedures or who have comprised bone quality are poor candidates for graft harvest. Of concern with this technique is the substantial donor site morbidity associated with all graft harvesting procedures. Persistent (chronic) pain at the hip graft site occurs in approximately one third of patients.

Bone graft technologies are clearly the wave of the future. CINN surgeons believe if they can keep from going to the hip, they can decrease recovery time, risk of infection and the pain that is associated with iliac crest autograft. Bottom line: they can get better outcomes.

Therapy the Right Way Makes a Difference:
Patient Directional Preference Key Factor in Therapy Outcomes*

A recent study demonstrated that a subset of patients suffering from low back pain – those with a directional preference – had statistically better outcomes with therapy that matched their directional preference. Directional preference (DP) is defined as when certain posture or repeated movements in a single direction (flexion, extension, or side-glide/rotation) eliminate or reduce the back pain. The study showed that patients adhering to a therapy regimen concordant with their DP (Matched Group) had less pain, used less medication and could perform more activities than patients who were taught exercises non-concordant with their DP (Opposite Group) as well as subjects taught commonly prescribed multi-directional, exercises and stretches recommended by established clinical guidelines (Evidence-Based Care Group).

The Matched Group reported significantly greater improvement than the other two groups in all five areas of satisfaction with care:

• Return to work
• Home activity
• Recreational activity
• Perceived need for further treatment
• Self-rated improvement

In summary, exercises concordant with a patient’s DP significantly improve patient outcomes. The highly experienced and trained physiatrists at CINN play a critical role in prescribing and monitoring conservative therapy, thereby increasing the likelihood of positive patient outcomes.

*Source: Audrey Long, BScPT, Ron Donelson, MD, Tak Fung, PhD, “Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain,” SPINE 29, no. 23 (2004): 2593-2602.