Choosing the Right Doctor
In order to find the right doctor, it is important to do your homework. The United States has the best health care in the world, but not all doctors have the same level of training and expertise. Consider the following when you are looking for a specialist:
Changes in medicine happen every day. Therefore, it is important to seek a physician that is up-to-date with the latest approaches to your problem.
Orthopaedic Surgery subspecialized considerably over the past decade. Many orthopaedic surgeons receive additional training in one of these major areas: Hand, Joint Replacement, Pediatrics, Sports, Shoulder and Elbow, Spine, Trauma, or Tumor. Fellowship training is the highest level training possible for a surgeon. Fellowships provide intense training in one specific area of the body. In total, spine surgeons require 10 years of additional training after graduating from college!
Which doctor is best?
In general, it is best to see a physician that has a special interest in your problem. However, there is often overlap between subspecialties. For instance, hand and shoulder surgeons may both treat elbow problems.
Orthopaedic Spine vs. Neurosurgeons
Orthopaedic surgeons and neurosurgeons usually have similar approaches, as long as their practice is dedicated to spine surgery. Although training is very different between the two disciplines, what is most important is the amount of time the physician focuses on the spine, and whether they keep up with latest techniques.
With scoliosis and kyphosis, both spine and pediatric orthopaedic surgeons treat children 18 years old and under. The major difference is that spine surgeons treat people of all ages so there is no rush to make decisions. Also, because they focus only on the spine, they have added experience. The most difficult scoliosis cases typically occur in adults, so pediatric procedures tend to be more straightforward.
Other Sources of Information
Health care plans typically provide very little input when it comes to picking a specialist. Their goals are to contain costs, even though high quality specialists may get you back on your feet quicker with the latest minimally invasive techniques.
It is also important to be careful when using the internet as a guide. The internet is a rich source of information, and misinformation.
Best Treatment for Spine Problems
The best treatment for spine problems is a fellowship-trained physician that focuses only on the spine. Ideally, multiple forms of imaging will be readily available to help provide a diagnosis as quickly as possible, and avoid taking additional time off from work or school for added appointments. Spine surgeons work closely with neurologists, rehabilitation and pain specialists, physical therapists, and alternative medicine experts to provide a multidisciplinary approach to your problem. In reality, only a small percentage of patients that see a spine specialist ever need surgery.
Do I Need a Spine Specialist?
Spine specialists focus only on the spine, and keep track of the latest advancements in non-operative and operative care.
Neck pain that radiates into the shoulder and/or down the arm is often due to a pinched nerve in the neck. Pain that begins in the wrist, or increases with moving the shoulder, are often due to local problems in the arm.
Low back pain that radiates into the buttocks and/or down the leg is often due to a pinched nerve in the back. Pain predominantly in the groin or side of the hip is often due to hip problems. Similarly, pain in the knee that increases with walking or bending the knee is typically a knee problem.
The vast majority (over 90%) of all spine patients improve with noninvasive, conservative management. We only recommend spine surgery as a last resort, and have strong relationships with chiropractors, physical therapists, pain and rehabilitation specialists, acupuncturists, napropaths, and holistic medicine experts to make sure you receive the most conservative care that takes care of your pain.
What Do My Symptoms Mean?
Neck pain that is limited to the width of your neck is often due to muscular spasm. These symptoms can last a long time, particularly after car accidents and other serious injuries. Neck pain that radiates into the shoulder and/or down the arm is often due to a pinched nerve in the neck.
Arm Pain, Numbness, or Weakness
Pain that begins in the wrist, or increases with moving the shoulder, are often due to local problems in the arm. However, pain that moves down your arm, or weakness in the arm can be due to a serious condition in your neck and should be evaluated by a spine specialist.
Low back pain or spasm that is limited to the muscles along the middle of the back, or pain that spreads widely across the waist area is often due to muscular spasms. Low back pain that radiates into the buttocks and/or down the leg is often due to a pinched nerve in the back.
Leg Pain, Numbness, or Weakness
Pain predominantly in the groin or side of the hip is often due to hip problems. Similarly, pain in the knee that increases with walking or bending the knee is typically a knee problem. However, pain that radiates down the front or back of the leg, particularly below the knee, is often due to a pinched nerve in the back. If you have progressive difficulty walking, or you have a foot drop (your foot slaps the ground as you walk), the weakness can be due to a serious condition in your back and should be evaluated by a spine specialist.
How Do I Relieve My Back or Neck Pain?
Most pain in the back or the neck is due to muscular irritation, and can be treated with stretching, exercises, and over-the-counter medications. It is important to be patient, stay active, and do your exercises every day. You may find the pain is much better when you do your exercises, and gets worse when you do not. This reemphasizes the importance of regular activity and exercise. Also, you can minimize your risk of reinjury by paying attention to proper lifting techniques.
Here are a few rules of thumb for treating your neck or back pain at home:
Ice vs. Heat Packs
Typically angry muscles prefer colder temperatures right after an injury, and more chronic muscular pain responds better to heat. However, there is no danger in trying both methods or alternating at any point in time. Be careful not to fall asleep on the heating or cooling pad, because you may seriously injure your skin.
Anti-inflammatory medications such as Ibuprofen, Alleve, or Tylenol can be taken in symptomatic or therapeutic doses. Please be sure to contact your general doctor if you had problems with stomach ulcers, or kidney/liver problems in the past, as these medications may become dangerous, even at safer doses. Also, be careful not to take Tylenol in addition to other medications that contain Acetominophen (Tylenol) such as Norco, Vicodin, or Darvocet.
When you have significant pain, short periods of rest are a good idea. It is important to remember that every day you do not use your core muscles while lying down, they become weaker. It will take added time to recover the strength you lose if you rest too much.
It is always safe to walk. Your body releases natural pain medications when you walk, and the increased blood flow is good for maintaining strength, and improving muscular pain.
What Are My Treatment Options?
In theory, there are three basic forms of treatment for the spine. Not all forms of treatment are appropriate for all patients:
This includes non-invasive treatments such as physical therapy, massage/deep tissue release, stretching, regular exercise, and various medications. Other options may also be incorporated depending on the diagnosis: chiropractic modalities, acupuncture, holistic medicine, among others. Regular exercise and stretching can help patients avoid surgery, and prevent reinjury.
Spinal injections can be directed toward neck or back pain, or radiating pain, depending on the diagnosis. Typically, a short acting anesthetic, or strong anti-inflammatory (cortisone) is used.
The goals are usually two-fold:
- To make you feel better!
- To help diagnose your pain generators.
Remember that there can be a delay between when the injection is given, and when the pain goes away. It is important to keep track of your symptoms over time, and speak to your physician about them. No one understands your body better than you do.
Surgery is only necessary in a small percentage of patients that visit a spine specialist, but it is important your care provider has a strong sense of all your options. Surgery is typically recommended in the following conditions:
- When we understand the pain generators, and all other treatment options are not adequately controlling the pain.
- When there is progressive pain or weakness that does not improve with conservative management.
- In scoliosis, when curves progress beyond a certain size, depending on the age and symptoms of the patient.
The most important component is understanding the pain generators, and setting your expectations for surgery. Some surgeons only recommend conservative management or injections if you refuse surgery, or try to scare you with threats of future paralysis. Beware! In other cases, surgery cannot help at all, or may make you worse. Therefore, it is important to see a specialist with a strong commitment to avoiding surgery unless it is absolutely necessary.
As a leading spinal revision specialist, Dr. Rinella takes pride in avoiding the problems that may lead to additional surgery down the road. He may be able to help you, even in situations where others told you there were no other options.
What are the Latest Advancements is Spine Surgery?
There are a number of exciting areas of research related to the spine:
Minimally Invasive Surgery
We are constantly working toward relieving spine and nerve pain through the smallest incision possible. What is more important than the size of the incision(s) is the amount of soft tissue we must disrupt between the skin and the spine. Through microinvasive techniques and the use of the latest operative microscopes, we can often approach the spine with minimal muscular irritation. Studies show that patients treated with minimally invasive techniques typically heal faster.
Over the past 10 years, companies developed disc replacements for the neck and low back. The idea is to avoid several problems associated with fusions:
- Avoid Bony Healing Time
bones typically take 6-8 weeks to heal, sometimes longer. By placing a mobile spacer between the bones, we do not need to worry about immobilizing the body, and this bony healing time is unnecessary. This typically allows for a quicker recovery period.
- Avoid Added Pressure on Neighboring Motion Segments
when a disc is fused, the level above and below have to absorb a bit more pressure due to the lack of motion in the fused segment. Sometimes this motion can lead to early breakdown of the neighboring segments. By allowing the discs to continue to move, there will be no additional stress on the adjacent segments.
However, with every advancement, there are risks:
- Breakdown Over Time
Just like knee or hip replacements, all metal motion surfaces eventually wear out. It is one thing to do a revision of a hip or knee procedure, because the implants are close to the skin. However, in the spine, revision of these implants is much more difficult, and potentially dangerous. The disc replacements are not alive like a fusion mass, so the body has no ability to heal it over time.
- Positioning is Critical
if the implant is not placed perfectly, it may not move at all, and most of the potential benefits go away. Many spine surgeons believe disc replacements in the neck are better use of the technology, because they have to carry much less weight.
Dynamic Rod Technologies
several companies are working with different rod types including relatively flexible materials to limit the pressure on the neighboring levels.
Short Segment Fusions
advanced pedicle screw designs (the screws we use in the spine) allow us to take firm control of the levels we are going to fuse. This often allows us to place very little if any restrictions after surgery, shortens recovery times, and improves fusion rates. This is especially true in scoliosis surgery, where we try to keep the majority of the spine as mobile as possible.
Advanced Spinal Alignment Techniques
sometimes the spine is fused in a bad position, or the body leans forward or to the side over time. Dr. Rinella has been one of the leading surgeons in complicated bone-cutting procedures (osteotomies) in the Chicago area for the past 7 years.
Is There Disc Surgery Without Fusion?
There are a number of exciting options to treating the pain associated with a pinched nerve in the neck or low back. The most obvious step is to avoid surgery in the first place! This is possible in over 90% of patients with radiating symptoms from disc herniations through conservative management and epidural steroid injections. However, if everything else fails and surgery is necessary, there are a number of exciting options:
Depending on the position of the herniation, microscopic discectomies can help relieve pain without fusion. This type of surgery is very common in the lumbar spine (low back), but is also possible in the cervical (neck) and thoracic spines. Patients typically require less than 2 weeks to recover from minimally invasive procedures.
An exciting new technology recently approved for use in the United States is disc replacement surgery. Please see here for more information. Like a knee or hip replacement, the goals are: to maintain motion, to avoid stress on other parts of the spine, and to avoid the time necessary for bones to fuse together. Many studies proved that patients with disc replacement can return to their normal lifestyle sooner after a disc replacement, than fusion - if disc replacement is indicated for their specific problem.