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Mc crae seminar ppt _feb2015sb
- 1. Finally, free yourselffrom chronic neck and back pain
- 2. Shaun McCrae, D.C., PhD •Doctor of Chiropractic, Texas Chiropractic College • PhD, Biomedical Science Chiropractor
- 3. Presentation Outline • Neck andback pain overview • Anatomy of the spine • Spine conditions • Treatment options • Open spine surgery • Minimally invasive spine surgery • Minimally invasive decompression (MID) procedures • Minimally invasive stabilization (MIS) procedures • Other procedures • About Laser Spine Institute • Questions and answers
- 4. • Problem sharedby 65 million Americans • 90% of the population is affected • No. 1 complaint by patients • 50–60% will recover within one week • 90% will recover within three months Neck and back pain overview: Neck and back pain is a widespread problem
- 5. Anatomy of thespine: Overview • Cervical • Thoracic • Lumbar Thoracic Lumbar Cervical
- 6. Anatomy of thespine: Detail • Vertebral body • Intervertebral disc • Spinal cord • Spinal nerve root • Foraminal canal Intervertebral disc Vertebral bodySpinal nerve root Foraminal canal Spinal cord
- 7. • Spinal canal Anatomyof the spine: Axial view • Disc • Spinal cord • Facet joint • Foraminal canal Facet joint Foraminal canal Spinal canal Spinal cord Disc
- 8. • Chronic, localneck or back pain • Radiating or traveling pain • Sciatica • Muscle weakness • Numbness and tingling in the legs or arms • The sensation of heat or pins and needles • Stiffness Spine conditions: Bulging/herniated disc Herniated disc
- 9. • Weakness inthe extremities • Numbness • Severe neck and/or back pain • Restricted movement • Radiating pain in arm and leg Spine conditions: Bone spurs Bone spurs
- 10. • Intermittent pain •A deep, dull aching • Headaches • Facet joint inflammation • Tenderness near the inflamed joint • Difficulty twisting or leaning backward • Stiffness, particularly in the morning Spine conditions: Arthritic facets Arthritic facet
- 11. • Continued/chronic pain • Newspine conditions • Pain above or below the treated level • Limited mobility • Dependence on prescription drugs Spine conditions: Failed back surgery syndrome
- 12. • Local pain •Numbness or tingling in the extremities • Muscle weakness • Traveling pain along the nerve • The feeling of pins and needles or heat Spine conditions: Foraminal stenosis Foraminal stenosis
- 13. • Pain inthe affected area of the spine • Pain radiates to hips and extremities • Numbness • Stiffness • Cramping in the legs • Difficulty standing or walking • Muscle weakness Spine conditions: Spinal stenosis
- 14. Treatment options: Medications • Anti-inflammatories •Muscle relaxers • Painkillers
- 15. • Chiropractic • Painmanagement • Physical therapy • Acupuncture • Traction Treatment options: Conservative
- 16.
- 17. Open spine surgery: Disadvantages •Requires hospitalization • Expensive • Long, painful recovery • Blood loss • Scar tissue
- 18. Open spine surgery: Disadvantages L4-5disc protrusion Conventional open spine surgery for herniated disc
- 19. Minimally invasive spine surgery Isthere a more effective alternative?
- 20. Minimally invasive spinesurgery
- 21. Minimally invasive spinesurgery
- 22. Minimally invasive spinesurgery
- 23. Minimally invasive spinesurgery: Tools • Rongeur • Burr • Endoscope • Camera • Laser
- 24. Minimally invasive decompression(MID) procedures: Foraminotomy Used in treating: • Foraminal stenosis • Pinched nerves • Bone spurs • Bulging/herniated discs
- 25. MID procedures: Laminotomy Used intreating: • Spinal stenosis • Bulging/herniated discs • Pinched nerves
- 26. MID procedures: Discectomy Used in treating: •Bulging/herniated discs • Pinched nerves
- 27. MID procedures: Facet thermalablation Used in treating: • Degenerative facet joints • Facet arthritis • Facet disease • Facet hypertrophy • Facet joint syndrome
- 28. Minimally invasive stabilization(MIS) procedures Used in treating: • Herniated discs • Degenerative disc disease (DDD) • Scoliosis • Spinal stenosis • Unstable spine • Spondylolisthesis • Swelling of the spinal cord (myelomalacia)
- 29. MIS procedures • CervicalDisc Replacement • ACDF (Anterior Cervical Discectomy and Fusion) • LLIF (Lateral Lumbar Interbody Fusion) • TLIF (Transforaminal Lumbar Interbody Fusion) • SI Joint Fusion
- 30. RegenaDISC® promotes healingthrough stem cell treatment and minimally invasive spine surgery techniques. • The treatment is performed within 90 minutes or less with the patient being discharged after approximately 1–2 hours in recovery. • Stem cells are collected from a patient’s bone marrow or fat cells and injected into the painful disc. • Stem cells regenerate the disc after repair, promoting healing and a return to spine health. Other procedures: Disc treatment
- 31. About Laser SpineInstitute: Minimally invasive spine surgery advantages Laser Spine Institute minimally invasive procedures Traditional open neck and back surgery Hospital stay Outpatient 2-5 days Infection rate 0.13% Up to 4.7% Muscle disruption Small incision, muscle sparing, muscles separated Muscles cut, torn
- 32. About Laser SpineInstitute: Advantages • More than two-thirds of patients report returning to work within three months after surgery • We perform more minimally invasive outpatient procedures each month than any other spine surgery provider in the nation • 97% patient recommendation rate • No lengthy recovery • Less than a 1-inch incision • Minimally invasive outpatient procedure • Board-certified surgeons • 96% patient satisfaction rate
- 33. About Laser SpineInstitute: Streamlined patient experience
- 34. About Laser SpineInstitute: Locations • Tampa, FL • Scottsdale, AZ • Philadelphia, PA • Oklahoma City, OK • Cleveland, OH • St. Louis, MO • Cincinnati, OH
- 35. About Laser SpineInstitute: The leader in minimally invasive spine surgery
- 36.
- 37. from neck andback pain Finally, free yourself Take the next step • A Spine Care Consultant will call you in the next few business days. • Instructions for sending your MRI are in the Seminar Guide. • MRIs will be reviewed following the presentation. • Please complete the survey.
- 38.
Editor's Notes
- #2 (SPINE CARE CONSULTANT) On behalf of Laser Spine Institute, I’d like to welcome you to today’s medical seminar. If you have not been seen yet by Dr. McCrae he will be glad to review your MRI following the presentation. We will also have a question and answer session at the end of our time together.
- #3 Here is a look at my credentials.
- #4 Here’s a quick overview of the information we’ll explore. We’ll see just how widespread the problem of pain really is … learn about the anatomy of the spine … discuss some of the conditions that cause neck and back pain. We’ll explore four treatment approaches to pain: medicines, conservative therapies, open spine surgery, and minimally invasive spine surgery. I’ll introduce you briefly to Laser Spine Institute, and will answer your questions at the end.
- #5 Neck and back pain are very common. 65 million Americans suffer with back pain, to some degree, each year. 90% of the population will be affected at some time in their lives. In fact, it’s the number one complaint that patients express to their physicians. That’s all the bad news. The good news is that if you develop back pain, 50 to 60 percent of the time, it’s going to get better on its own in one week. If you wait long enough, 90% of people recover within three months. Now if you have severe, unremitting back pain … pain radiating down your legs … most people don’t want to wait three months to see if it’s going to go away. In fact, how many here have been in pain more than three months? More than six months? More than a year? How about more than five years? To grasp why this is such a widespread problem, it’s helpful to understand the anatomy of the spine.
- #6 The spine is composed of three sections: the cervical region or neck, thoracic or mid-back, and the lumbar region or low back. The most frequently injured region of the spine is the lumbar spine, closely followed by the cervical region. The least-frequently injured section is the thoracic region because it has the protection and support of the surrounding rib cage.
- #7 If we zoom in a little bit, we see the individual building blocks of the spine, which are these vertebral bodies. Between each of these vertebral bodies is a disc. Some patients refer to these discs as shock absorbers. They’re actually pretty sturdy structures. In fact, if you were to put pressure on the spine, you’re more apt to break a bone than to injure or rupture one of those discs. Directly behind the vertebral body and disc, we see the spinal cord. It passes through the spinal canal. Exiting on the right and left side, at each level, are these nerve roots. They pass through an important structure called the foraminal canal. Finally, this is the facet joint.
- #8 Now I just switched from a side view to something called an axial view. So what we see here is the disc. And I’m circling the tough, outer durable layer of the disc called the annulus fibrosis. It surrounds a soft, gelatinous center, which is the nucleus pulposus. That’s where the cushion comes from. Directly above the disc, we see the spinal cord. The nerve roots pass on the right and left sides. And finally, these are the facet joints. We have joints in our back just like we have joints in our hips or knees. Now that you understand a little bit about the anatomy of the spine, let’s explore some of the conditions that cause neck and back pain.
- #9 If someone has a herniated disc, how many believe that condition will always cause neck or back pain? The answer is that it often doesn’t. Studies have been done where MRI images are obtained from groups of people who have no complaints of back or neck problems. Lo and behold, up to 30 percent of those imaged have at least one herniated disc. And at least 60 percent of those people have at least one bulging disc. You don’t do surgery on them; if they are not causing pain. You might have an MRI report that describes multiple bulging or herniated discs, but chances are, not every one of those discs are causing pain. When there is pain, typically it’s because the disc is pinching a nerve. Symptoms can include chronic neck or back pain, pain that radiates down the arms or legs, sciatica, muscle weakness, numbness, tingling, the sensation of burning or pins and needles, and stiffness.
- #10 Bone spurs, also called osteophytes, are enlargements of your body’s normal bone structure. As these enlargements progress, they may protrude into surrounding tissues, sometimes causing pain and other symptoms. Now bone spurs that are pinching the nerves are going to cause the same sort of pain as a bulging disc. Reviewing an MRI allows us to determine what is causing the pain. Symptoms of bone spurs may include weakness in the extremities, numbness, severe neck or back pain, restricted movement and pain that radiates down the arms or legs.
- #11 A healthy joint is a hinge at the end of bones and is usually coated by cartilage and lubricated by synovial fluid. Normally, joints move easily with very little friction, but natural degeneration of the joint can cause the cartilage to become rough and worn out. This can result in joint halves rubbing against one another, causing inflammation, the formation of bone spurs, stiffness, and pain. If you have arthritis, you may experience intermittent pain or a dull ache, headaches, or inflammation… In addition, you may have difficulty twisting, and may be stiff in the mornings.
- #12 Just to be clear … we do not do laminectomies. But we see a lot of people who have already had one of those procedures. A laminectomy is a very invasive open back procedure. After a few years, many people go back to see the surgeon who did it because their pain has returned. But if you’ve already gone through an open back procedure, you don’t typically want to go through another one. As you can see, those who have had a previous open spine surgery can suffer from a wide range of painful conditions.
- #13 At every level of the spine, the nerves exit through a small canal. This canal is called the foramen or foraminal canal. Foraminal stenosis is a narrowing of this canal. Nerve roots leaving the spine are typically constricted by bone spurs, a herniated or bulging disc, arthritis or ligament thickening. Foraminal stenosis can also be caused by enlargement of a facet joint. It can produce a type of pain called radicular pain, which is pain that radiates into the lower extremity directly along the course of a specific spinal nerve root. Other symptoms may include muscle weakness, numbness or tingling, and a sensation of heat or pins and needles.
- #14 Spinal stenosis is narrowing of the canal to the point where the nerves in the middle are being pinched, be it at the core or the nerve roots of the lower spine. What we see is a severe compression of the spinal cord from multiple factors. There’s a bulging disc narrowing the canal. There are arthritic joints that have gotten bigger, and spurs that have formed on there, narrowing the canal. Spinal stenosis usually happens in someone who’s a little older. They have back pain, leg pain, or both. And it’s aggravated by standing or walking. Typically, they get relief by sitting or leaning forward. Does anybody have those symptoms? It’s about 90% accurate that spinal stenosis is at least part of that reason. What does the doctor usually do for someone who is suffering with back pain?
- #15 One of the treatment options with neck or back pain is medications. For the primary care doctor, that’s what you have at your disposal … a prescription pad. To write a prescription to help people get better. Let’s talk about the different drugs we use. Anti-inflammatories decrease inflammation and swelling. They all increase the blood pressure a little bit … thin the blood. And can cause bleeding ulcers. Have any of you been prescribed muscle relaxers for your neck or back pain? Muscle relaxers … decrease muscle spasticity. If you have a neck or back problem, you might develop muscle spasms, which make that pain even worse. The problem with muscle relaxers is sedation. The big problem with painkillers is two-fold. Addiction is the first thing. When I’m talking about painkillers, I’m talking about narcotics … things that people can get very addicted to. If you stop taking these types of strong medicine, your body will go into withdrawals if you’ve been taking them on a regular basis. Now the other problem with narcotics is tolerance. The longer you’re on them, the higher the dosage or the stronger the medication you need. If you’re still having pain, despite taking these kinds of medications, let me go over a few kinds of things people do to get over that pain.
- #16 Let’s go over these conservative treatment options. The first one on the list is chiropractic. Does anybody go to see a chiropractor? If someone can get good relief from an adjustment, then it’s probably not time for surgery. Pain management doctors … does anyone go see them? In addition to prescribing the narcotics we talked about, they also provide epidural steroid injections, right into the location of where the pain is coming from. The steroid decreases inflammation, takes a lot of swelling away from nerves that are being pinched, and can make you feel better. How about physical therapy? Has anybody seen a physical therapist? Now physical therapists can do some of the things that a chiropractor can, some adjustments … but what I really like them for is building your core muscle strength and teaching you how to avoid getting into positions that are going to aggravate the condition you have. Has anyone tried acupuncture? Did it help? Yes? Medical science has proven that acupuncture can help. This is inserting needles into certain parts of your body, and those needles cause your body to release endorphins, your body’s own natural painkiller. Traction is one on our list. Has anyone tried that? Otherwise known as the DRX9000, the most common traction machine. You lie down on this table, get strapped in, and they stretch you out a little bit. The idea is that if they can stretch you enough, they put a little height back in that disc that has collapsed. Maybe they can pull that herniation back in so it’s not pinching nerves. For some conditions, traction is probably not going to help at all. Can anyone tell me what might be a common problem with all these treatments? They are only temporary solutions. The medications on the prior page, the conservative treatments here, it just highlights that people do just about anything they can to try and get over their pain. If you’re still having pain, this is probably the point that you consider surgery.
- #17 Let’s talk about open back surgery. The laminectomy is the most common surgery that’s done for backs. A big incision is made in a person’s spinal canal, right along it, and retractors hold the tissue apart. Basically, we see that the spinous process has been cut off at the back of all these levels, it’s going to be followed by cutting out the back side of that canal, taking the roof off the canal, and then they close it up. Has anyone had a physician suggest open spine surgery to you? This is a major surgery. It takes time to perform because they’re cutting away all this muscle here. There’s a procedure that’s even more invasive than this where a patient lie son their back during the surgery, and the surgeon starts by cutting through their abdominal wall, pulls them aside, pushes their intestines over, and then fuses them from the front. Then they flip them over, and do this procedure. Those kinds of surgeries can take a long time … 8, 10, 12 hours.
- #18 Specific disadvantages to open spine surgery. Number one: major surgery like this has to happen in a hospital. We like to highlight that because we’re an outpatient surgery center. At a hospital, you have higher costs and an increased risk of infection. Recovery from open spine surgery is very long and very painful. When there’s a lot of tissue taken out of your body, it takes a long time to heal. The blood loss is high. And a lot of scar tissue can form. The scar tissue is not just that unsightly scar on the back or neck. The scar tissue that we worry about is within the spinal canal. Scar tissue can surround nerves, and reverse any advantage you had from the surgery in the first place. At this point, it can become it become a permanent problem. Has anyone here already had an open spine procedure?
- #19 This is an MRI of a young woman we saw about four years ago at a seminar like this one. 38 years old, young woman, had an injury on the job, a slip and fall accident. Just to orient you to the anatomy, the vertebral bodies are these grey blocks, the disc is highlighted between L4 and L5, and you see it’s protruding or bulging out a little bit. The spinal cord is up there… the nerve roots within the canal. Now, see these discs here… how they have a lot of white fluid in them? But this disc is a little darker? So technically, the disc between L4 and L5 is degenerative. So for this problem, she was referred to see an orthopedist. And that orthopedist treated her with this surgery. Two levels, fused together, six screws, two rods … and that’s still a typical open spine surgery for this condition.
- #20 We propose a different alternative. Minimally invasive spine surgery. It’s the more effective alternative to open neck or back surgery.
- #21 As you can see here, a minimally invasive procedure is dramatically different than the highly invasive approach we saw in the open back surgery. Instead of the large 3- to 6-inch incision, our approach only requires an incision of less than 1 inch. A thin probe is going to pass through the skin to the backside of the spinal canal, and there are a series of tubes that go past that probe. This spreads the muscle fibers so that we can gain access to the spinal canal without having to cut the muscle out. There’s this thin tube, then a little larger, then finally a larger tube.
- #22 We can see one of our surgeons doing an operation right here. He’s looking down here. The tube is very small in this person’s back. There’s a camera mounted on top of that tube. The camera displays on these large monitors so the surgeon can see magnified about 50 times what’s going on within the spinal canal. He’s doing a minimally invasive outpatient procedure right here.
- #24 Let me share with you the specific tools that we use during operations. The first two instruments: a rongeur and a burr. These are used to get through bone. The rongeur is highlighted here. This is how we cut away, with quite a bit of precision, just enough bone to take pressure off pinched nerves. We bite a little bone, pull that out, remove it, clean it off and go back, and get a little bit more. The burr is like a dremel … a little spinning tool. What we do with the burr is smooth off rough edges. We use rigid endoscopic tubes to separate muscle fibers. The advantage of doing surgery through this endoscope is that it minimizes cutting. Once we’re done with surgery, we pull the tube out, the tissue we separated collapses back in. Camera is just for the visual, so we can see clearly what’s going on. And the laser is used for soft tissue, and to cauterize and vaporize little sensory nerves within arthritic joints. We do not use the laser to cut bone because the energy required would be extremely high. And that amount of energy is going to generate too much heat. So while the laser is an important tool, it is not used in all our procedures.
- #25 There are several types of surgical procedures performed by Laser Spine Institute. The first is called a foraminotomy. Remember, the foraminal canal is a little canal where the nerves exit. And if it is narrowed, for whatever reason, be it scar tissue, bulging disc or bone spur, we are actually able to go in and open up that foraminal canal by doing a foraminotomy. A foraminotomy is opening up the canal so the nerve that is exiting through that canal is no longer pinched. And when the nerve is no longer pinched, there’s relief from pain. Does anyone have pain that begins in your neck or back and runs down into your legs or arms? A foraminotomy may be one of the procedures that provides you with relief.
- #26 We treat stenosis by opening up the spinal canal with a minimally invasive procedure. We do a small incision, place a thin probe in the muscle, over that probe we pass dilating tubes. And then we do surgery through that tube to cut away a little bit of the bone. The name of this surgery is laminotomy … putting a hole in the lamina to allow the spinal cord to expand. This is much different from the laminectomy, which is the open back surgery that removes the whole lamina.
- #27 The way we treat herniated discs here at Laser Spine Institute is with the laser. We vaporize part of the disc material. It actually shrinks it down. It decompresses it. I like to tell patients it’s like letting air out of a tire. It shrinks it down or retracts it away from away from the nerve, and the pain goes away. Because Laser Spine Institute uses the laser, we’re able to toughen the disc, strengthen it, and put it back in its place.
- #28 Now, if a person’s pain is limited to the back, the question is going to be “Is it coming from the stenosis, which is a narrowing of the spinal canal, or is it coming partially from the arthritis, or both?” We do a test before surgery to help figure that out. The test is called a diagnostic facet injection. That’s numbing up these joints with numbing medicine. It’s a Novocain-type medicine, like they use at a dentist’s office. We numb the facet joint, have the patient stand up and walk around. If the pain goes away, then we know that the pain was coming entirely from the arthritis. Has anyone here had a root canal? A Facet Thermal Ablation is a procedure very similar to a root canal a dentist performs. The surgeon uses a laser to clean the facet joint and deaden the nerve that innervates the joint and causes painful symptoms. The facet joints are the joint structures that connect the vertebrae to one another. Thermal ablation refers to the laser eradication of the effected nerve.
- #30 coflex® device helps to stabilize the spine Decompresses both sides of the spine for immediate stabilization Maintains long-term decompression
- #32 There are many advantages to minimally invasive spine surgery when compared to open back surgery. With minimally invasive spine surgery, nearly 80% of patients are back to work within 3 months. With open back, 65% remain disabled two weeks after surgery. Minimally invasive spine surgery has no hospital stay, compared to as much as five days. Our infection rate is only 0.35%, while open back surgery is as high as 4.5%. Our complication rate is only 4%, while 31% of those who have open back surgery have complications.
- #33 In addition to the advantages of minimally invasive spine surgery in general, there are a number of advantages specific to Laser Spine Institute. We are more experienced because we perform more of this type of surgery than anybody else in the nation. We’ve helped more than 40,000 patients since 2005. More than 80% of our patients travel from out of state for surgery. That just shows that our procedures are not widely available, and patients are willing to travel to take advantage of our expertise. Integrated service – that means we coordinate everything needed in a very timely manner. Now, patients can have an outpatient work-up through their primary doctor, but usually that takes weeks or months for referrals to get certain tests done … we can definitely expedite the process. Success rate – our lumbar success rate is 87% … cervical success rate is 95%. But what I usually get asked next is what happened to the 13% who didn’t get better after their back surgery? The good news is that, nobody has paralysis, no major problems. But, there is a percentage of patients for whom the degree of improvement does not meet their expectations. That said, our success rate is very high. Our infection rate is very low … part of that is due to our very small incision, and the other part relates to our widely recognized safety standards.
- #34 If you decide to proceed with surgery, we have a streamlined patient experience where you can go from initial evaluation to postoperative appointment in just a few days. On the first day, we’ll perform a new patient evaluation, history, physical … do EKGs, bloodwork, get updated MRIs and X-rays, if needed. Then– you meet with the physician, go over your images, and if any diagnostic tests are needed, those are done that day. These tests can include a diagnostic facet injection, selective nerve root block, MRI and discograms. At that point, we usually have a good idea of what surgery is going to be done, and we can assign the surgeon. The day before your surgery, you will meet your anesthesia provider. On surgery day, you’ll meet again with your surgeon and anesthesia provide to discuss your procedure. The surgery only takes about one hour, and you’re back on your feet within a couple of hours. In most cases, the day after surgery is a day of rest. We encourage you to walk a couple of times each day. After that, you’ll visit us again for your postoperative follow-up appointment. . All this means is that we’re going to check the surgery site, make sure everything looks okay, give you some thorough instructions and then you can go home. The duration of the experience will vary for each patient.
- #35 Those are the centers where we do surgery – Oklahoma City, Philadelphia, Scottsdale and Tampa.
- #36 If you’re suffering with chronic neck or back pain, and conservative treatments aren’t providing the relief you’re looking for, consider Laser Spine Institute. Our minimally invasive procedures are an effective alternative to open neck or back surgery.
- #38 (SPINE CARE CONSULTANT) Thanks Doctor. I want to let everyone know that a Spine Care Consultant will call you in the next few business days to see if you have additional questions. If you didn’t have an MRI with you today, there are instructions for how to send one in on the back of your Seminar Guide. If you have your MRI with you, and have not met with the doctor yet, we’ll be calling your name shortly. And before you go, please complete the survey we provided to you. After leaving the seminar today, the next step is yours. Our goal has been to inform you about the causes of neck and back pain, explore the treatment alternatives available today, and empower you to make a decision about which approach is right for you. We look forward to helping you in the days to come.
- #39 Thank you everyone for attending today’s seminar. Have a great day.