the way i see it

the way I see it

starbucks coffee cup -- the way I see itI perform spine and hip surgery and I see patients in consultation in my office in Monterey, California.  I have written this guide so that you will know in more in advance about my practice philosophy.  I am a direct and open communicator and I strive to educate patients as completely as possible.  I use the medical literature as a guide towards treatment decisions — what we refer to as evidence based medical practice — but please understand that I do have my own biases and opinions.  I am presenting those biases and opinions here so that you may decide in advance if we are likely to form a constructive doctor-patient relationship.

 

If we examine the causes of disability in the United States of America, we find that arthritis and back and neck pain is identified as a cause of disability in 30% of the population and this is more than all of the other major causes of disability in the US combined.  These are copies of slides from one of my talks on common causes of back pain…click on the thumbnail image to enlarge the slide.

spinal disease and arthritis causes the majority of disability in the united states  80 percent of people have an episode of back pain during a year  only 10% require an operation

When someone with back or neck pain is referred to a spine clinic, reasonable guidelines suggest that 100% of those patients need to be educated about their condition, 80% would probably benefit from physical therapy, 20 to 30% may need some sort of a minor medical intervention such as an injection, and less than 10% of patients should require operative intervention.  In my practice, it is quite common to see a patient who has had a 1 to 2 month history of low back pain with an MRI scan of the lumbar spine that is described as showing disk bulging and degenerative changes.  This patient is often taking narcotics on a daily basis and states that he or she has tried physical therapy a few times and “failed”.  They are now seeking answers and further care.  Often, this patient is obese, sedentary, and from the perspective of someone who lives in coastal california, leads a relatively unhealthy lifestyle.  This type of patient is often unhappy with the results of their consultation with me because they have unrealistic expectations about how medical science can help them.  Let us examine each of these elements so that we can understand why….

The four things that everyone with back pain should know:

  1. The MRI scan is normally abnormal
  2. Narcotic pain medications are not a great idea for open-ended diagnoses
  3. PT involves more work than you think
  4. Lifestyle choices have a huge effect on back pain
cambodia10

Children’s surgical center — phnom phen, cambodia

Children’s Surgical Center is a non-governmental organization (NGO) run by Dr. James Gollogly, MD FRCSC, in Phnom Phen, Cambodia. This program provides technologically appropriate surgical services and training in a developing country. At our office in Monterey, California, we collect surgical supplies and equipment for the hospital in Phnom Phen. In 2007 I performed the first total hip arthroplasties and instrumented spine surgeries to be done in Cambodia. I have an active and ongoing program of helping to train surgeons in Cambodia in some of these techniques. Here is a link to a brief clip on youtube to a short segment of a documentary on CSC…

Children’s Surgical Center

Currently, in Cambodia, a population of more than 12 million people suffers under a significant burden of disease from land mine injuries, trauma, traffic accidents, and congenital abnormalities, without access to appropriate medical care. More information about Children’s Surgical Center can be found at www.csc.org, and a summary of the challenges of delivering medical aid in a country like cambodia are summarized in this article published in the British medical journal, The Lancet.

Cambodia — Challenges of Aid.

Children’s Surgical Center is dedicated to improving medical care in Cambodia by providing surgical training to Cambodian surgeons in their own environment, with diseases that they frequently encounter.

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Research interests

The Vertical Expandable Prosthetic Titanium Rib

The vertical expandable prosthetic titanium rib or VEPTR, was invented by a surgeon in San Antonio, Texas, named Bob Campbell, in the early 1990’s. Fourteen years later, in 2004 the device was approved by the Food and Drug Administration (FDA) for the treatment of Thoracic Insufficiency Syndrome under a special category called HDE.

Thoracic Insufficency Syndrome is a new diagnosis. It didn’t exist ten years ago, and it wasn’t until March of 2003 when an article was published by Dr. Campbell in the Journal of Bone and Joint surgery (www.jbjs.org) that the concept recieved the widespread recognition that it deserves. Currently, thoracic insufficiency syndrome is defined as a failure of the thorax to support normal respiration. Clinically, this means that the chest is either too small, or doesn’t work right, so the patient can’t get enough oxygen to live a normal life.

This syndrome is thought to occur as a consequence of severe spinal deformities that occur in very young children, or as a consequence of spinal fusion surgery at a young age.

These two pictures are the x-rays of the chest of a young child with progressive scoliosis of the spine. The treatment options for a curve of this size, at this age, are limited, but include things like bracing, growing rods, early fusion, or treatment with the VEPTR device. Each of these options has it advantages and disadvantages, and the decision about which treatment strategy is most appropriate is currently a great source of debate amongst some of the most senior and experienced spine surgeons in the world.

congential scoliosis of the spine  congential scoliosis of the spine

In this case, this child was treated with an opening wedge thoracostomy on the convex side of the curve and two titanium ribs were placed. An opening wedge thoracostomy means that the side of the chest was surgically opened, and a space between the ribs was created, and then held open by the smaller of the two devices in the picture below. This part of the procedure is designed to make more space for the lung, in the hopes that it will expand to a larger size. A second rib has been placed from near the top of the chest to near the bottom of the spine in order to partially correct the scoliosis.

Each of these ribs will be lengthened, usually every six months, in a short surgical procedure through a small incision, in order to keep up with the child’s growth. It is not known for certain if all children who are treated with a rib will also require a full spine fusion when they are old enough, but it seems likely that most will.

congential scoliosis of the spine after VEPTR insertion  congential scoliosis of the spine after VEPTR insertion

The results of this form of treatment are the subject of many ongoing clinical trials. There is a study group that consists of surgeons, pulmonologists, clinical researchers, and engineers from the Children’s Hospitals in San Antonio, Boston, Philadelphia, Los Angeles, Salt Lake City, Pittsburgh, Philadelphia, and Seattle. This group meets three of four times a year and investigates the results of this type of surgery and presents the results to national and international meetings of pediatric orthopedic surgeons and spine surgeons for further dicussion.

CT reconstruction of the lungs and thorax  CT reconstruction of the lungs and thorax  CT reconstruction of the lungs and thorax

As part of this study group, my research is focused on using CT scans to look at lung size and shape. The three pictures here illustrate how a CT scan can be used to create a three dimensional model of the lungs inside the chest. This data is useful for evaluating how big a child’s lungs are before, and after treatment. New CT scan technology may allow us to look at how the lung responds to surgery and may also help us to improve upon the technique and understand when is the best time to perform surgery.

I frequently get requests for workable copies of the pediatric lung volume charts.   These data were published in the following paper: Gollogly S, Smith JT, White SK, Firth S, White K. The volume of lung parenchyma as a function of age: a review of 1050 normal CT scans of the chest with three-dimensional volumetric reconstruction of the pulmonary system. Spine. 2004 Sep 15;29(18):2061-6.

The charts can be downloaded in PDF format using the following links, and they have been subdivided into two different age groups: 0-18 years of age, and 0-8 years of age. The 0-8 year charts are designed to improve the resolution of these data in determining relative lung volume during the more critical phases of lung growth and surgical decision making.

Unpublished data on changes in lung density during growth are also available from birth to 18 years of age as derived from a smaller cohort of 334 children that had non-contrast CT scans of the chest. These data are currently reported for total lung volume and density only, but charts for right versus left lung densities are in the works.

Management of pediatric fractures

Pediatric Fracture Clinic

Surgical approaches for difficult deformities of the spine

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Papers and presentations

Published papers

  • Roussouly P, Gollogly S, Berthonnaud E, Labelle H, Weidenbaum M. Sagittal
    alignment of the spine and pelvis in the presence of L5-s1 isthmic lysis and
    low-grade spondylolisthesis. Spine (Phila Pa 1976). 2006 Oct 1;31(21):2484-90.
    PubMed PMID: 17023859.  Link.
  • Hunt KJ, Gollogly S, Randall RL. Surgical fixation of pathologic fractures: an
    evaluation of evolving treatment methods. Bull Hosp Jt Dis. 2006;63(3-4):77-82.
    PubMed PMID: 16878822.
  • Roussouly P, Gollogly S, Noseda O, Berthonnaud E, Dimnet J. The vertical
    projection of the sum of the ground reactive forces of a standing patient is not
    the same as the C7 plumb line: a radiographic study of the sagittal alignment of
    153 asymptomatic volunteers. Spine (Phila Pa 1976). 2006 May 15;31(11):E320-5.
    PubMed PMID: 16688022.
  • Sailhan F, Gollogly S, Roussouly P. The radiographic results and neurologic
    complications of instrumented reduction and fusion of high-grade
    spondylolisthesis without decompression of the neural elements: a retrospective
    review of 44 patients. Spine (Phila Pa 1976). 2006 Jan 15;31(2):161-9; discussion
    170. PubMed PMID: 16418634.
  • Smith JT, Gollogly S, Dunn HK. Simultaneous anterior-posterior approach
    through a costotransversectomy for the treatment of congenital kyphosis and
    acquired kyphoscoliotic deformities. J Bone Joint Surg Am. 2005
    Oct;87(10):2281-9. PubMed PMID: 16203895.
  • Newton PO, Faro FD, Gollogly S, Betz RR, Lenke LG, Lowe TG. Results of
    preoperative pulmonary function testing of adolescents with idiopathic scoliosis.
    A study of six hundred and thirty-one patients. J Bone Joint Surg Am. 2005
    Sep;87(9):1937-46. PubMed PMID: 16140807.
  • Gollogly S. Do as I say, not as I do. Lancet. 2005 Apr 23-29;365(9469):1499.
    PubMed PMID: 15850635.
  • Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal
    variation in the sagittal alignment of the human lumbar spine and pelvis in the
    standing position. Spine (Phila Pa 1976). 2005 Feb 1;30(3):346-53. PubMed PMID:
    15682018.
  • Gollogly S, Smith JT, White SK, Firth S, White K. The volume of lung
    parenchyma as a function of age: a review of 1050 normal CT scans of the chest
    with three-dimensional volumetric reconstruction of the pulmonary system. Spine
    (Phila Pa 1976). 2004 Sep 15;29(18):2061-6. Review. PubMed PMID: 15371709.  Link
  • Gollogly S, Smith JT, Campbell RM. Determining lung volume with
    three-dimensional reconstructions of CT scan data: A pilot study to evaluate the
    effects of expansion thoracoplasty on children with severe spinal deformities. J
    Pediatr Orthop. 2004 May-Jun;24(3):323-8. PubMed PMID: 15105731.  Link.
  • Sailhan F, Chotel F, Guibal AL, Gollogly S, Adam P, B√©rard J, Guibaud L.
    Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur
    Radiol. 2004 Sep;14(9):1600-8. Epub 2004 Apr 3. PubMed PMID: 15064854.
  • Brockmeyer D, Gollogly S, Smith JT. Scoliosis associated with Chiari 1
    malformations: the effect of suboccipital decompression on scoliosis curve
    progression: a preliminary study. Spine (Phila Pa 1976). 2003 Nov
    15;28(22):2505-9. PubMed PMID: 14624085.  Link.
  • Brodke DS, Gollogly S, Bachus KN, Alexander Mohr R, Nguyen BK. Anterior
    thoracolumbar instrumentation: stiffness and load sharing characteristics of
    plate and rod systems. Spine (Phila Pa 1976). 2003 Aug 15;28(16):1794-801. PubMed
    PMID: 12923465.
  • Brodke DS, Gollogly S, Alexander Mohr R, Nguyen BK, Dailey AT, Bachus aK.
    Dynamic cervical plates: biomechanical evaluation of load sharing and stiffness.
    Spine (Phila Pa 1976). 2001 Jun 15;26(12):1324-9. PubMed PMID: 11426146.  Link.

Posters and Presentations

  • 39th Annual Scoliosis Research Society. Sept 6-9, 2004. Buenos Aires, Argentina. The Thoracic Distortion Index Predicts the Effect of Spinal Deformities on Pulmonary Impairment. Gollogly S, Smart M, Smith J.
  • 39th Annual Scoliosis Research Society. Sept 6-9, 2004. Buenos Aires, Argentina. The Sagittal Alignment of the Spine and Pelvis in the Presence of L5-S1 Isthmic Lysis and Low-Grade Spondylolisthesis. Roussouly P, Gollogly S, Berthonnaud E, Labelle H, Widenbaum M.
  • 39th Annual Scoliosis Research Society. Sept 6-9, 2004. Buenos Aires, Argentina. Classification of the Sagittal Alignment of the Spine in the standing position. Roussouly P, Gollogly S, Berthonnaud E, Labelle H,
  • 39th Annual Scoliosis Research Society. Sept 6-9, 2004. Buenos Aires, Argentina. Is the center of gravity located at the bottom of the C7 plumb line? Roussouly P, Gollogly S, Noseda O, Berthonnaud E, Dimnet J.
  • 39th Annual Scoliosis Research Society. Sept 6-9, 2004. Buenos Aires, Argentina. Lung Density Decreases as Thoracic Volume Increases after Expansion Thoracoplasty in The Treatment of Jarcho-Levine Syndrome. Gollogly S, McKellar A, White S, Smith J, Campbell R.
  • 39th Annual Scoliosis Research Society. Sept 6-9, 2004. Buenos Aires, Argentina. Changes in Lung Density with Growth: The Results of a Computed Tomography Study in 334 Normal Patients. Gollogly S, McKellar A, White S, Smith J.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. Sagittal Hypokyphosis Varies with the Location of the Apex of the Coronal Curve: Is There An Explanation That Suggests An Etiology in Idiopathic Scoliosis? Gollogly S, Faro F, Marks M, Newton P.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. The Sagittal Alignment of the Spine and Pelvis in the Presence of L5-S1 Isthmic Lysis and Low-Grade Spondylolisthesis. Roussouly P, Gollogly S, Berthonnaud E, Labelle H.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. Classification of the Normal Variation in the Sagittal Alignment of the Lumbar Spine and Pelvis in the Standing Position. Roussouly P, Gollogly S, Berthonnaud E, Dimnet J.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. Is the center of gravity located at the bottom of the C7 plumb line? Roussouly P, Gollogly S, Noseda O, Berthonnaud E, Dimnet J.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. Does reduction of high-grade spondylolisthesis require decompression of the neural elements? Roussouly P, Gollogly S, Salihan F.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. The Thoracic Distortion Index Predicts the Effect of Spinal Deformities on Pulmonary Impairment. Gollogly S, Smart M, Smith J.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. Lung Density Decreases as Thoracic Volume Increases after Expansion Thoracoplasty in The Treatment of Jarcho-Levine Syndrome. Gollogly S, McKellar A, White S, Smith J, Campbell R.
  • 11th International Meeting on Advanced Spine Techniques (IMAST). June 31st – July 3, 2004. Bermuda. Changes in Lung Density with Growth: The Results of a Computed Tomography Study in 334 Normal Patients. Gollogly S, McKellar A, White S, Smith J.
  • Scoliosis Research Society International Traveling Fellows’ Visit. May 19-22, 2004, Children’s Hospital San Diego. Lung Volume Assessment in Scoliosis. Gollogly S.
  • Scoliosis Research Society International Traveling Fellows’ Visit. May 19-22, 2004, Children’s Hospital San Diego. Idiopathic, Congenital, Neuromuscular, and Syndromic Scoliosis Management. Gollogly S.
  • 31st Annual David H. Sutherland Pediatric Orthopedic Visiting Professorship. May 13-14, 2004, Children’s Hospital San Diego. Instrumented Reduction and Fusion of High-Grade Spondylolisthesis Without Decompression: The Lyon Experience. Gollogly S, Salihan F, Roussouly, P.
  • 31st Annual David H. Sutherland Pediatric Orthopedic Visiting Professorship. May 13-14, 2004, Children’s Hospital San Diego. Intermediate-term results in the Treatment of Scoliosis with the Vertical Expandable Prosthetic Titanium Rib. Gollogly S, Smith JT, Campbell RM.
  • Pediatric Orthopaedic Society of North America. April 29-May 2, 2004. St Louis, MO. The effect of Expansion Thoracoplasty on Lung Volume in Congenital Scoliosis With Fused Ribs. A Pilot Study of 10 Patients using CT Scan Reconstruction of the Lung. Smith JT, Gollogly, S, Smart M.
  • 38th Annual Scoliosis Research Society. Sept 10-13, 2003. Quebec City, Canada. Normal Lung Development in Children: The Results of a Review of 940 3-Dimensional Ct Scan Reconstructions of the Thoracic Cavity in Normal Children. Smith JT, Gollogly S, White S, White K.
  • 38th Annual Scoliosis Research Society. Sept 10-13, 2003. Quebec City, Canada. Simultaneous Anterior-Posterior Approach via \Costotransversectomy for the Treatment of Complex Congenital and Acquired Kyphosis. An Old Operative Technique Revisited. Smith JT, Gollogly S, Dunn HK.
  • 38th Annual Scoliosis Research Society. Sept 10-13, 2003. Quebec City, Canada. Determining Lung Volume by Three-Dimensional Analysis of A/P and Lateral Radiographs. Smith JT, Gollogly S, Campbell RM.
  • 10th Annual International Meeting on Advanced Spine Techniques (IMAST). July 10-12, 2003. Rome, Italy. Simultaneous Anterior-Posterior Approach via Costotransversectomy for the Treatment of Complex Congenita and Acquired Kyphosis. An Old Operative Technique Revisited. Smith, JT, Gollogly, S., Dunn, HK.
  • 10th Annual International Meeting on Advanced Spine Techniques (IMAST). July 10-12, 2003. Rome, Italy. Determining Lung Volume by Three-Dimensional Analysis of AP and Lateral Radiographs. Gollogly, S., Smith, JT., Campbell, RM.
  • Pediatric Orthopaedic Society of North America. May 1-4, 2003. Amelia Island, Florida. The Treatment of Jeune’s Asphyxiating Thoracic Dystrophy by Dynamic Segmental Postero-Lateral Expansion Thoracoplasty with a Vertical Expandable Prosthetic Titanium Rib. Campbell, R, Smith, JT, Gollogly, S.
  • Pediatric Orthopaedic Society of North America. May 1-4, 2003. Amelia Island, Florida. Assuming the Burden of Pediatric Fracture Care in a Children’s Medical Center…Efficiently!. (Poster Exhibit #48). Smith, JT, Gollogly, S, Clark, NC.
  • Pediatric Orthopaedic Society of North America. May 1-4, 2003. Amelia Island, Florida. Simultaneous Anterior-Posterior Approach Via Costotransversectomy for the Treatment of Complex Congenita and Aquired Kyphosis. An Old Operative Technique Revisited. Smith, JT, Gollogly, S, Dunn, HK.
  • Pediatric Orthopaedic Society of North America. May 1-4, 2003. Amelia Island, Florida. Image Analysis of the Results of Expansion Thoracoplasty on Children with Complex Deformities of the Spine. Gollogly, S, Smith, JT, Campbell, RM.
  • 37th Annual Scoliosis Research Society Meeting. September 18-21, 2002. Seattle, Washington. The Effect of Opening-Wedge Expansion Thoracostomy on Thoracic Insufficiency Syndrome: A Pilot Study Using CT Scans and Voxel Holography to Determine Changes in Lung Volumes. Smith, J.T., Gollogly, S., Campbell, R.
  • 9th Annual International Meeting on Advanced Spine Techniques (IMAST). May 23-25, 2002. Montrose, Switzerland. The Effect of Opening-Wedge Expansion Thoracostomy on Thoracic Insufficiency Syndrome: A Pilot Study Using CT Scans and Voxel Holography to Determine Changes in Lung Volumes. Smith, J.T., Gollogly, S., Campbell, R
  • 9th Annual International Meeting on Advanced Spine Techniques (IMAST), May 23-25, 2002. Montrose, Switzerland. Scoliosis Associated with Chiari 1 Malformations. The Influence of Surgical Decompression on Scoliosis Curve Progression. Smith, J.T., Gollogly, S., Brockmeyer, D.
  • Pediatric Orthopaedic Society of North America Annual Meeting, May 3-5, 2002. Scoliosis Associated with Chiari 1 Malformations. The Influence of Surgical Decompression on Scoliosis Curve Progression. Smith, J.T., Gollogly, S., Brockmeyer, D.
  • Orthopedics Grand Rounds, University of Utah Department of Orthopedics. Chiari 1 Malformations and Scoliosis. March 17th, 2002, Salt Lake City, Utah. Gollogly, S.
  • 17th North American Spine Society Annual Meeting, Seattle, Washington, November 2001. Scoliosis associated with Chiari I malformations. The influence of surgical decompression on scoliosis curve progression. Smith, JT, Brockmeyer D, and Gollogly S.
  • Orthopedic Trauma Association Annual Meeting, San Antonio, Texas, October 2000. The clinical outcomes of bicondylar tibial plateau fractures treated with lateral buttress and anteromedial antiglide plates. Peters CL, Gollogly S, and Horwitz DS.
  • Western Orthopedic Association Annual Meeting, Scottsdale, Arizona, September 2000. Clinical results of proximal humerus fractures treated with an intramedullary nail. Horwitz DS, Gollogly S, and Peters CL.
  • Cervical Spine Research Society Annual Meeting, Seattle Washington, December 1999. Dynamic cervical plates: do they load share at the expense of stiffness? Brodke DS, Gollogly S, Nguyen B,
  • Orthopedic Trauma Association Annual Meeting, Charlotte, North Carolina, September 1999.Anterior for stabilization of thoracolumbar burst fractures: a biomechanical comparison. Brodke DS, Gollogly S, et al. (poster exhibit).
Nora-Volkow

Narcotic pain medication — too much of a good thing?

Many patient who see me in consultation have been prescribed narcotic pain medications for their back pain.  In my experience, this is often the beginning of a slowly developing disaster.  Typically, the patient is initially offered a prescription of anti-inflammatory medications by their primary MD which has a modest effect.  However, if the patient still perceives that pain is present, if they have taken a painkiller for some other problem in the past, or if they simply ask for something stronger, they are often offered a prescription for a narcotic.  Examples of narcotic pain medication include Norco, Vicodin, Oxycodone, and Lortab.  These are opiate medications that are in the same class of molecules as Heroin and Morphine and their effect upon the brain is still incompletely understood.  Recent research suggests that one of the effects of taking these drugs is an increase in levels of neurotransmitters — tiny little molecules that buzz around our brains and effect how we feel — such as Dopamine that are associated with generalized feelings of satisfaction, accomplishment, and meaning.  After taking these medications for a short period of time, the patient experiences the opposite emotions if the drug is not taken regularly.  This typically results in an increase in feelings of anxiety, depression, lack of purpose, and more PAIN.  For a fascinating discussion of this area of research, click here for a recent interview with Nora D. Volkow, the scientist who is in charge of the National Institute of Drug Abuse. (http://www.nytimes.com/2011/06/14/science/14volkow.html)

Nora Volkow a general in the drug war

The first image in the next sequence of pictures is from the marketing campaign for a new narcotic pain medication.  In my mind, there is not much difference between the first image and the second.  Both are using advertising to deceptively suggest that a substance has less risk than it really does.  One thing is certain, the rate of narcotic pain medication consumption is skyrocketing.  The Drug Control and Access to Medicine Consortium, which is based at the University of Wisconsin, tracks world wide per capita opiate use.  The consortium publishes a fascinating interactive map and chart of world wide per capita opiate consumption online.  Click here for the DCAM web site.

nucynta opiate poster  marlboro man annual opioid consumption oxycodone use in 1995  oxycodone use in 2007  opiate consumption as a function of GDP

 

These charts speak for themselves.  The United States has the highest rates of per capita opiate consumption and the largest year upon year increases.  For example, in 1995, each citizen in the United States on average consumed about 10mg per year of Oxycodone, but by 2007, this rate increased to 140 mg of Oxycodone use per year per person.  This represents a staggering increase.  Some of the factors contributing to this increase include aggressive marketing by pharmaceutical companies, increased expectations on behalf of the patient, and increased permissiveness on behalf of physicians.  Narcotic pain medications are important tools and they are indispensable in the management of fractures, post-operative pain, pain caused by cancer, and other ailments.  IN MY OPINION, the use of narcotics for the management of back and neck pain without nerve root impingement is inappropriate.  Back pain is typically an open ended experience — meaning that there is rarely a defined point in the future when we know the pain will diminish.  This is unlike the situation faced by a patient who has a fracture or post-operative pain, for example.  If someone has a fractured bone, with reasonable certainty we know that the fracture will heal within 6 to 8 weeks and the pain will typically subside.  I have no problem giving someone with a fracture a prescription for narcotics because it is likely that the pain will subside within a reasonably short period of time and the patient will stop using the narcotics before they become “habit-forming”.  However, if someone starts taking narcotics for back pain, I frequently them, “When will you know that its time to stop?”  If they answer is, “When all of my pain is gone”, then this is a very unrealistic expectation and is likely to result in a long period of narcotic use which in turn leads to narcotic addiction.  While there are many doctors and patients who believe that narcotics are a reasonable drug to use for the management of neck and back pain, I do not.  I respectfully acknowledge that there are many medical experts and patients in this country who believe that pain is still being under-treated in the US but I do not provide the service of ongoing narcotic based management of pain.

 

Take home message #2: if you are not a candidate for surgical treatment, you will not be offered narcotic pain medication.

next topic: physical therapy involves more work than you think

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Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica

Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica

Stadnik TW, Lee RR, Coen HL, Neirnyck EC, Buisseret TS, Osteaux MJ.

Department of Radiology and Medical Imaging, University Hospital V.U.B., Brussels, Belgium.

PURPOSE: To evaluate the prevalence and radiologic findings of annular tear (especially of contrast material enhancement), bulging disk, and disk herniation on T2-weighted and gadolinium-enhanced T1-weighted magnetic resonance (MR) images in people without low back pain (LBP) or sciatica.

MATERIALS AND METHODS: Thirty-six volunteers without LBP and/or sciatica (18 with no symptoms in their lifetime and 18 who were pain free for at least 6 months) were examined with sagittal and axial T2-weighted fast spin-echo (SE) and sagittal gadolinium-enhanced T1-weighted fast SE imaging. The prevalence and MR findings of bulging disk, focal protrusion, extrusion, and nonenhancing or enhancing annular tears were assessed.

RESULTS: The prevalence of bulging disk and focal disk protrusion was 81% (29 volunteers) and 33% (12 volunteers), respectively. There were no extrusions. Twenty-eight annular tears were found in 20 patients (56%); 27 tears (96%) also showed contrast enhancement.

CONCLUSION: Annular tears and focal disk protrusions on MR images, with or without contrast enhancement, are frequently found in an asymptomatic population. Extruded disk herniation, displacement of nerve root, and interruption of annuloligamentous complex are unusual findings in an asymptomatic population and can be more closely related to patients with LBP or sciatica.

physical therapy3

I went to physical therapy but it didn’t work…

The most frequent prescription that I write is for physical therapy.  My standard scrawl on a prescription pad reads: “Low back pain.  Lumbar spine stabilization and core conditioning exercises.  Teach independent home exercise program.  Frequency: 2-3 times per week for 6 weeks.”  This translates into 12 to 18 visits over 6 weeks with a therapist, with each session lasting about an hour.  I have worked with a number of physical therapists over the years and the ones that get the best results are able to motivate the patients to do the core strengthening and conditioning exercises describe in our home remedy book.

    

Unfortunately, many patients are under the impression that physical therapy should feel like a spa session.  They are expecting the therapist to massage the sore muscles of the back, apply a hot pack to the lower lumbar spine, and magically take the pain away.  This does not work.  The most effective physical therapy programs emphasize ACTIVE rehabilitation, which means that the patient is the one doing the exercise.  Furthermore, this process has to happen outside of the the PT gym.  It is impossible to reverse years of neglect of the muscles that lend stability to the spine with only 18 hours of physical training over 6 weeks.  In my clinical practice I will often seen patient back after they have been going to PT for four to six weeks, and the patients who do well with physical therapy are the ones that put forth a genuine effort establish a routine that they incorporate into their daily lives.  It typically takes 3-4 months to strengthen the core muscles to the point where the patient will notice an improvement in their low back pain.  It takes even longer for the patient to notice physical changes in their body that they can be proud of.  I am fond of saying that I’ll have to quit practicing medicine on the day that the model from the cover of Men’s Journal comes into clinic complaining of back pain, because so far, it just hasn’t happened.  The patients that tell me that PT did nothing for them tend to have more in common with a jellyfish than the guy with six pack abs on the cover of the men’s journal.

jelly fish  mens journal

Take home message #3: physical therapy involves a lot of hard work, and if you aren’t willing to do the work, you won’t get any of the benefit.

next topic: lifestyle choices have a huge effect on back pain

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There is a relationship between back pain and lifestyle choices

It shouldn’t come as a surprise to anyone reading an article on back pain that there is an epidemic of obesity in america.  There is no doubt in my mind that as weight increases, there is a proportional increase in back pain.  I believe that one of the reasons for this correlation is that our skeletons are simply built to carry less load.  In this series of images that come from the very enlightening movie Food, Inc., we see a parody of the classic illustration of the ascent of man to the point where the anatomic structures of the spine are simply overwhelmed by mass they have to carry and move.

While it has been very difficult to prove that obesity is directly correlated with an increased amount of back pain, there is no doubt that obesity contributes to a sedentary lifestyle and the combination of the two is bound to give you a back ache.  This is a very sensitive subject to broach with patients.  Several studies have weighed in (pun intended) on either side of the issue of whether or not it is advisable to discuss weight issues with patients and the results have often been contradictory.  Some authors believe that obesity should be directly discussed with patients and there are patients who are apparently unaware of the ill effects of obesity.  There are also others who believe that identifying obesity as the cause of symptom can often undermine the therapeutic relationship because the patient feels criticized or judged.  In my experience, this has been very difficult terrain to navigate.  I have had a number of patients who have come to see me with back pain, with an abnormal MRI scan, after a failed course of physical therapy, and who are substantially overweight.  I have found that it is very difficult to please this patient since meaningful weight loss is a very difficult goal to achieve, and exercise is hard when you already have back pain.

I am very sympathetic to plight of people who have gained a significant amount of weight and I acknowledge the extreme difficulty associated with trying to lose weight in the setting of obesity AND back pain or arthritis.  However, I do believe that obesity and a sedentary lifestyle do contribute to back pain and I feel that it is my responsibility as a surgeon to discuss this with patients.  I am close personal friends with Dr. Mark Vierra who is a world renowned general and laparoscopic surgeon with a very busy weight loss/bariatric practice and we have discussed this issue on many occasions.  I frequently refer patient’s to Dr. Vierra’s monthly lectures at Community Hospital on the subject of weight loss, and if you are interested in attending one of these lectures: please click here.  I am often asked for an opinion on dietary advice.  I rely heavily on the author Michael Pollan who wrote the book Food Rules and was a key figure in the documentary Food Inc.  There are three things that I ask everyone who wants to discuss dieting to read or watch.  The first is Food Rules (here’s the summary: eat less, not too much, mostly plants!), the second is the following article on caloric restriction from the New York Times (http://www.nytimes.com/2009/10/11/magazine/11Calories-t.html), and the third is the documentary Food Inc.

  

 

Take home message #4: if you have a BMI of 30 or greater, chances are that I will tell you that your weight is a contributing factor to your back pain.  Here is a link to a body mass index calculator: http://www.nhlbisupport.com/bmi/  Ultimately, I am very happy to discuss these issues with patients, but that conversation typically is more enjoyable for both parties when my biases and opinions are known in advance.

checklist manifesto

Pre-operative checklists

An operation is a series of steps, and the steps need to be followed in sequence.  The same is true of pre-operative preparation before any major surgical procedure.  Atul Gawande, who is a very enjoyable author, recently published a book called The CheckList Manifesto which explored the use of checklists to manage complex tasks like flying airplanes and performing surgery.  This book has become instrumental in shaping the procedures used at hospital to improve patient safety.  I like to use a series of checklists to make sure that the appropriate steps have been taken at each step along the way.  This process begins when we perform complete a history and physical examination, review the appropriate imaging data such as the MRI scan and X-rays, and determine a treatment plan.


surgical checklist cockpit tasks
  surgical checklist cockpit tasks  surgical checklist

Once the diagnosis is confirmed and you agree that surgical correction is desirable we will complete a pre-operative checklist that ensures that the following goals have been met:

  • You should be properly educated about the condition, the risks and benefits of surgery, and expectations for treatment
  • You should be evaluated prior to surgery by your primary MD and be considered “fit” to undergo a major operation
  • Pre-operative laboratory testing and an EKG has been completed
  • A surgical plan has been formulated and your questions have been answered.

Prior to the day of surgery, there are a few things that you can do that will improve the outcome after surgery.  The most important of which is a skin decontamination procedure.  Recently, the national institutes of health and several major medical centers around the united states have completed a series of clinical trials on what patients should do at home PRIOR to surgery in order to decrease the chances of developing an infection post-operatively.  These studies were specifically designed to find out whether or not a program of pre-operative decontamination resulted in a reduction in the number of post operative infections — and the answer was resounding — THESE PROGRAMS WORK.

The most common routine for preoperative decontamination of the skin involves using an ointment in your nose for 5 days prior to surgery and using a special type during your daily shower or bath 1 or 2 days before your operation.  First, the OINTMENT.  The nostrils (called the nares by medical doctors) is a warm and inviting place for bacteria to set up shop.  Approximately 25 to 30 percent of the general population has a particular type of bacteria in their nostrils called MRSA — methicillin resistant staph aureus.  This is a very common bacteria that normally lives on the skin that has become resistant to antibiotics over the past 20 years and it is a common culprit in post-operative infections.  To reduce the chance that you are an MRSA carrier at the time of your operation, you apply an ointment called bactroban to the inside of your nostrils, twice a day for 5 days before the operation.  Bactroban is the brand name for the medication, Mupirocin is the generic name, and the tube looks like this.

bactroban surgical site infection prophylaxis

Second, the SOAP.  Your skin is covered with bacteria.  While the surgical team will clean your skin thoroughly before beginning a procedure, research has shown that using a particular type of soap called hibiclens during your shower for 1-2 days before surgery helps reduce the chance of an infection.  This soap is available in most pharmacies and it looks something like this.  We will also provide you with a prescription for this soap.

hibiclense surgical site infection prevention

It is important that you complete this cleaning routine prior to surgery because it has definitively been shown to reduce your chance of developing a surgical site infection post-operatively.

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Sohrab Gollogly, MD is a board-certified orthopedic surgeon and Fellowship-trained spine surgeon who also performs scientific research and participates in several volunteer surgical organizations.

Dr. Gollogly completed his undergraduate education in biology at Reed College in Portland, Ore. He earned his medical degree from the University of Washington School of Medicine.

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