About three years ago, I saw a patient with terrible back and neck pain. He is an elite tennis player, actor, singer—an all-around active and vibrant man. His pain was brutal, and it was severely affecting his personal and professional life. Surgery was clearly indicated, but the surgical approach was anything but straightforward.
Too healthy for fusion, too diseased for decompression
The man’s case created a conundrum, though one I see rather often in my practice. His spinal joints were clearly degenerating, but his discs looked relatively healthy. I could treat the impingement with a simple, minimally invasive procedure. If there had been no arthritis, that simple decompression probably would have relieved his pain.
However, he had the joint degeneration of a much older man. Had he been a much older, not an elite tennis player who loved his sport, perhaps I would have suggested what most surgeons offer in this case: spinal fusion. If I had, I could have relieved his pain, but turned him into an ex-tennis player. I wasn’t prepared to do that, and nether was he.
Spine surgery as a continuum: The transition zone of spine surgery
Chronic back pain treatments exist on a continuum. We usually start with modest interventions, perhaps an anti-inflammatory and some physical therapy. If these fail, we move to more advanced pain management strategies and spinal injections. Spine surgery is usually considered as the end of that continuum.
Over the last decade, I have come to view spine surgery options on a similar continuum. On one end of this continuum fall the cases that can be completely treated with minimally invasive techniques. These include procedures such as microdiscectomy and nerve decompression. These approaches can provide pain relief while preserving spinal motion. However, they are rarely permanent solutions. Most patients will require additional spinal procedures within a decade.
On the other end of the continuum is spinal fusion. Spinal fusion can provide profound and often permanent pain relief. However, spinal range of motion is severely limited, especially when fusion of multiple levels is required. Patients must trade mobility for pain relief. For some, this is a welcome trade. For others, they would be giving up too much. Especially when we have other surgical options that exist in the middle of the continuum, in a space I call the transition zone.
The transition zone includes procedures that are more permanent and invasive than microdiscectomy but preserve spinal motion better than fusion. The two procedures I would place in this transition zone are interlaminar stabilization and artificial disc replacement.
In the transition zone: Interlaminar stabilization
The patient I described lies firmly within the transition zone of back pain surgical procedures. He could not be satisfactorily treated with minimally invasive techniques, nor would spinal fusion provide him with the freedom of motion he would need to maintain his active lifestyle. I offered him a microdecompressive surgery and placement a relatively new device called Coflex to relieve facet joint loading pressures on his arthritic spinal joints. The Coflex interlaminar stabilization device is a U-shaped titanium device that fits between the one or two contiguous L1-L5 spinous processes. The device preserves natural motion at adjacent levels and good mobility at the treated levels.
In this active tennis player, this “transition zone” treatment was ideal. It has been three years since I performed the procedures and his has had excellent results. Of course, he may eventually need another spinal surgery, but if he is able to get 10 or even 20 years of spine mobility without substantial pain, that is a win.
In the transition zone: Artificial disc replacement
I also place artificial disc replacement in the transition zone. This approach is best for patients with degenerating discs and relatively healthy facet joints. My personal history with spinal surgery provides a good example. I have three artificial discs in my lumbar spine and one in my cervical spine next to a fusion. I opted for replacement to preserve mobility in the spine. My tennis game is not as good as my patient’s is, but I was not willing to surrender my spinal range of motion to the fusion zone.
Remember the transition zone
My hope is that spine surgeons and chronic back pain patients will begin to conceptualize back pain surgery as a broader, fuller continuum. There are options between microdecompression and fusion. Just as surgery is the non-surgeon’s last option to treat back pain, spine fusion should be the spine surgeon’s last resort in most patients. Many patients may eventually enter the fusion zone, but if we can postpone that day by decades while maintaining pain-free mobility and function, shouldn’t we first offer treatments in the transition zone whenever possible?
A Diplomate of the American Board of Neurological Surgery and a Fellow of the American College of Surgeons, Dr. Todd H. Lanman leads his spinal neurosurgery practice, Lanman Spinal Neurosurgery in the heart of Beverly Hills, which is affiliated with Cedars-Sinai Medical Center, UCLA Medical Center and Saint John's Medical Center.
Dr. Lanman earned his MD at Chicago's Northwestern University in 1983 with top honors and went on to complete his residency in Neurological Surgery at University of California at Los Angeles, under the aegis of Doctors W. Eugene Stern and Donald Becker in 1989. Since then, Dr. Lanman has led his spinal neurosurgery practice in the heart of Beverly Hills, which is affiliated with Cedars-Sinai Medical Center, UCLA Medical Center and Saint John's Medical Center.
As a leading innovator in medicine, as well as a media educator and contributor, Dr. Lanman has published more than 10 peer-reviewed articles, as well as book chapters on topics relating to neurological surgery, and has presented more than two dozen papers at national and regional medical society meetings. His expertise is often sought out as he is often tapped to be the principal medical investigator on a wide swath of clinical trials for motion preserving surgeries and artificial disc replacement devices, most recently the Prestige LP and M6, with the former recently receiving FDA pre-market approval on July 6, 2016, through his continuous support. He has also remained an assistant clinical professor at UCLA for the past 20 years. Check out Dr. Lanman's website at http://www.spine.md
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