The Truth About Minimally Invasive Spine Surgery

If you have had back or neck surgery in the past few years, or if you suffer from neck or low back pain, you’ve probably heard about ‘minimally invasive spine surgery,’ which we’ll call MIS surgery here in Dr. Massey’s blog. What you may not know is how MIS is defined, who is actually qualified to perform it, and when it is an appropriate choice for you.

MIS surgeries are performed by both neurosurgeons and orthopedic spine surgeons. It is of course your job as the potential patient to make sure your surgeon is properly trained, and you should routinely ask your doctor how they were trained, how many of these operations he or she has performed, and with what success and complication rates.

MIS surgery is a philosophical approach to spine surgery in which the surgeon attempts to treat disorders of the spine and nerves with less damage to normal tissue than a standard, open procedure for the same problem. This means that the problem you are having surgery for is addressed via a shorter incision, with less blood loss, shorter operative times, and quicker recovery times than the “open,” or traditional surgery.

It is very important to understand that there is no guarantee that a MIS surgical procedure will produce a better outcome than a traditional approach. The ultimate decision as to whether your problem can be managed best by MIS surgery or open surgery depends on your anatomy, previous surgeries you have had, and the judgment and experience of your surgeon.

Let me close by saying this: successfully performing MIS surgery requires special training, years of experience working with microscopes, endoscopes, and ports, and a surgeon willing to constantly strive to improve and evolve their skills. Before you allow someone to cut into your body, research them, ask for patients you can talk with who have had similar procedures, and seek second opinions.

W. Lee Warren, MD
Auburn Spine and Neurosurgery Center
Auburn, Alabama
www.auburnspine.com

A Multidisciplinary Approach to Fibromyalgia

I have been working with fibromyalgia for the past fifteen years, leading a one-time group session called “Positive Coping Strategies for Fibromyalgia.” For many of the people that I have seen, this is the first time that they have had a chance to sit with other people who also have the diagnosis of fibromyalgia, and talk about its impact on their lives. Feeling misunderstood by others and having to explain their health challenges when they “look like they are fine” is a frequent topic, and being with a group of people who really understand can be very therapeutic.

So what do we talk about in the group? We talk about what they have learned “turns up the volume” of their pain and fibromyalgia symptoms, and more importantly, what they have learned “turns down the volume” of their pain and fibromyalgia symptoms. While we all agree that medications can be an important part of treatment for fibromyalgia, we also agree that medication alone is not the answer to learning to live with fibromyalgia. We talk about very practical ways to manage the pain, including the use of heat, ice, massage, stretching, Tai Chi, yoga, exercise, deep breathing, relaxation, and even aromatherapy. We talk about the importance of learning to focus on the here and now, learning how mindfulness and being “present” is a way to focus on what is important for that day.

Stress management is always an important part of our group, and includes listing stressors related to family life, work, and coping with the demands of life and the diagnosis of fibromyalgia. Talking about negative emotions like fear, anger, and sadness are inevitable topics of group, and learning how to balance the negatives with humor, fun, positive relationships, gratitude, and discovering meaning and satisfaction in life is part of the journey toward health. Discovering negative thinking and its impact on increased stress and pain is discussed, with strategies for eliminating this pattern. Grieving and letting go, finding a “new normal,” taking risks, being assertive, building resilience and hope, and taking care of themselves are also emphasized as essential ingredients of feeling better and functioning better.

We are in the process of creating a four-session group series (the “Mind Body Fibromyalgia Wellness Group”) that will allow time to cover all the previously mentioned topics in more depth, and to add time to practice skill-building with relaxation and breathing exercises, and perhaps some basic yoga and tai chi movements. My hope is that having four meetings with the same group of patients will allow us to have “homework assignments” that will help each person begin to make concrete changes that we will discuss in group within a supportive environment. Anticipated start date for the group series is April 2012.

Call Clinical Psychologists, PC at (334) 821-3350 for more information and to register for these groups. I will continue to offer the one-session group, “Positive Coping Strategies for Fibromyalgia,” until the new series begins. Hope to see you soon!

Dr. Peggy Howland, Licensed Psychologist
Clinical Psychologist, P.C., Auburn, AL

Fibromyalgia

Fibromyalgia is a diffuse musculoskeletal pain disorder with unknown cause. Several factors contribute to its development, including genetic predisposition in combination with physical and emotional stressors. It was first described inFranceandEnglandin the mid-nineteenth century and it was termed “fibrositis.” Upon reviewing muscle biopsies of patients affected with the condition, the term was changed to “fibromyalgia,” as there is no evidence of inflammation in the muscles.

Fibromyalgia seems to be caused by a dysfunction of the way the neurotransmitters work in the pain system. A neurotransmitter is a substance released by nerve cells that transmits information across the nervous system. Please note in the diagram below that the pain system (the same as the nervous system) begins at the periphery (such as the hand), marked #1. The sensation of pain travels from the periphery to the spinal cord (#2), and then to the brain (#3). In a dysfunctional system, there is no balanced release of neurotransmitters, which results in increased pain sensation, also known as central sensitization. It is like increasing the volume on a radio by transmitting or passing increased pain signals.

Please refer to the following diagram of the pain system to visualize how it works.

Published with permission from Pfizer.

Published with permission from Pfizer.

 

Adahli E. Massey, MD, FACR

Biologic Therapy in Rheumatic Diseases

A biologic drug is a drug used to treat diseases, such as rheumatic disease, in which there is a dysfunctional immune system. It modifies the biologic response in a disease state and is therefore named “biologic therapy.”

These drugs have greatly modified the way rheumatologists treat rheumatic patients, improving the patients’ prognoses and outcomes. In some studies, remission rates (percentage of patients with no evidence of active disease) have been as high as 60% when these drugs are used (Arthritis & Rheumatism Volume 52, Issue 1, pages 27-35, January 2005).

The standard of therapy at the present time is to institute therapy in rheumatoid arthritis patients as soon as within three months of the onset of symptoms; it has been demonstrated in clinical studies that most of the joint damage – and therefore the development of deformities and patients becoming crippled – occurs within 3-12 months of the onset of disease (Arthritis & Rheumatism Volume 54, Issue 3, pages 702-710, March 2006). To avoid delay in evaluation and treatment, we try to accommodate those patients with a presumed diagnosis of rheumatoid arthritis and an appointment within 3-4 weeks after contacting our office. These patients have to have a least one abnormal laboratory (either elevated rheumatoid factor or positive anti-CCP), swollen joints, and symptoms lasting more than six weeks. We understand the urgency of having these patients started on the right medicines as soon as possible.

Biologic therapy is also available for patients with psoriatic arthritis, lupus, and ankylosing spondylitis, other less common diseases, as well as children with idiopathic juvenile arthritis. These drugs do have potential side effects, one of the most important being that patients may be more prone to developing infections or having complications from infections. In future blogs, I will further address these issues, but for now I want to leave the reader with the knowledge of how beneficial these drugs have been to patients, especially those with inflammatory arthritides.

Adahli E. Massey, MD, FACR

Remission in Rheumatoid Arthritis

The ultimate goal of treating rheumatoid arthritis is achieving remission. The American College of Rheumatology and the European League Against Rheumatism – organizations created by physicians for the study, research, and education of rheumatic diseases – define “remission” in clinical practice as the patient having all of the following:

 

  1. Tender joints < 1 (one or less)
  2. Swollen joints < 1
  3. Patient global assessment < 1 (how a patient usually feels on a scale of 0-10, where 0 means the patient feels great and 10 means the patient has pain, stiffness, and is unable to perform daily activities)

 

For patients, this translates to a CDAI (Clinical Disease Activity Index) score of < 1. This is a questionnaire, including a physical exam, that calculates a scoring of disease activity. Remission is defined as a CDAI score of £ 2.8. The criteria are created for clinical trials, but clinicians should also follow the path for helping patients achieve remission. I have started using this index for some patients since the beginning of 2011, and it has helped to guide treatment for many of them.

So, now we don’t only strive to give patients better quality of life, but we also want to stop the progression of disease and the development of deformities or crippling damage.

Adahli E. Massey, MD, FACR

 

Ref: The Rheumatology Report Summer 2011

Infusion Services by Tashina Coleman, RN

The infusion center is the part of the clinic where I give patients intravenous (IV) infusions and subcutaneous injections. The IV infusions include: infliximab (Remicade), abatacept (Orencia), zoledronic acid (Reclast), rituximab (Rituxan), tocilizumab (Actemra), belimumab (Benlysta), and ibandronate sodium (Boniva). One of the subcutaneous injections I give is denosumab (Prolia); I also demonstrate and teach patients how to self-inject these medications at home. Every patient premedicates with Tylenol Arthritis and an antihistamine, unless instructed otherwise by Dr. Massey. We do this to reduce the chance of adverse reactions.

When a patient arrives, I call them back to my treatment room where I assess their vital signs, assess for current sickness or infection, and start their IV. The treatment duration varies according to the medication the patient receives. I check the patient’s vital signs (blood pressure, heart rate, and respiration) every thirty minutes during the infusion and upon completion.

We also treat patients from other physicians. I act as the liaison between the Arthritis Center and these physicians, communicating with them and sending office notes upon completion of each treatment. I do the same for Dr. Massey’s patients, keeping an open and frequent line of communication with their primary care physicians.

I enjoy performing infusions because I like helping people. This job is very emotionally rewarding. My most gratifying experience is when a patient has their first infusion and comes back to tell me how much better they feel.

Tashina Coleman, RN

Rheumatoid arthritis – What is it?

Rheumatoid arthritis (RA) is a disease in which the immune system does not function in its usual way and destroys joints, including the cartilage and bone. The cause of this disease is unknown, although it is thought that in a person with a family history of RA, an insult such as infection may trigger the immune system to develop the signs and symptoms of this disease.

The usual presentation of symptoms is pain, stiffness, and swelling in multiple joints; this could include fingers, wrists, elbows, shoulders, knees, hips, ankles, and toes. RA does not affect the spine, except in long-standing cases where it can affect the joints of the neck.

Laboratories frequently ordered to test patients for RA include markers of inflammation, such as ESR and CRP. Other helpful tests for diagnosis (not always present, especially at the beginning of symptoms) include rheumatoid factor and anti-citrullinated peptide antibodies.

We are able to diagnose RA much earlier these days with a new set of guidelines published by the American College of Rheumatology. The use of these guidelines provides patients with early intervention and treatment and a more favorable prognosis in terms of progression of disease and quality of life.

I will be providing more information about this topic in future blogs.

Adahli E. Massey, MD, FACR

Methotrexate in rheumatic diseases.

Methotrexate in rheumatic diseases.

Methotrexate is a medicine used to suppress the immune system. When the immune system is not working properly, it can cause diseases. It has been used in the treatment of rheumatoid arthritis since the 1980s. It is believed that Methotrexate increases adenosine – a substance that inhibits inflammation – in the body.

Methotrexate can be taken orally (liquid or tablets) or as an injection. It is usually taken once a week; I recommend taking it after supper so patients feel less nausea, which is one of the most common side effects.

Methotrexate has been proven to slow the progression of disease in several studies and it possibly does so in about 50% of patients. In other studies, it has been shown to improve symptoms and signs of rheumatic diseases. It also has a low incidence of side effects when used at the doses used fro rheumatic diseases. Overall, the American College of Rheumatology recommends the use of Methotrexate first for most moderate to severe cases of rheumatoid arthritis.

Other possible side effects include: mouth sores; hair loss (uncommon); bone marrow and liver toxicity (for which patients are asked to do frequent laboratory monitoring); lung reaction; rash; and lymphoma (possibly higher incidence due to disease, no medications).

Methotrexate should not be used with medicines such as Septra or Probenecid.

It is contraindicated during pregnancy and should not be used 6 months prior to conception.

It does not damage the kidneys, but because it is excreted through the kidneys, it should be avoided in patients with severe renal damage.

Laboratories should always be taken the day before, or the morning of, the day when the patient takes Methotrexate.

Adahli E. Massey, MD, FACR

What’s up with the “osteo” diseases?

Two frequent diseases that are commonly confused with one another are osteoporosis and osteoarthritis.

Osteoarthritis is a common joint disease due to multiple factors, including local inflammation, mechanical forces (use of the joints), genectic predisposition, and cellular dysfunction of the components of the joint. Osteoarthritis commonly affects the hands, shoulders, knees, hips, neck, and low back. It is more common after age 40, but trauma and other genetic factors could accelerate the time of onset.

Osteoporosis on the other hand, is decreased bone mass due to micro-architectural disruption with a resulting high risk for a fracture. Think about the construction of a building — if the frame is not properly built, then the building will collapse.

The diagnosis of osteoarthritis is usually based on the patient’s history, physical exam, and radiographic findings. Whereas in osteoporosis, DXA (a technique called dual-energy X-ray Absorptiometry) is used for the diagnosis. A patient who has had a fragility fracture (or low impact) is also considered to have osteoporosis. These patients should consult with their doctors when a fracture occurs to see if treatment should be instituted.

Adahli E. Massey, MD, FACR

What is lupus?

Lupus, or systemic lupus erythematosus (SLE), is an autoimmune disorder where the body produces antibodies against itself. Antibodies are proteins that are usually produced by the body to attack foreign things, such as bacteria and viruses. But in lupus, the antibodies (or autoantibodies) attack the cells of the body. This ‘attack’ causes the variety of symptoms that we see in lupus, including joint pain, rash, lung disease, mouth sores, kidney damage, brain damage, and so on.

The American College of Rheumatology has designated 11 symptoms/signs that are used for the diagnosis of the disease. Most rheumatologists use these criteria for the diagnosis of lupus. A patient has to have at least four of the 11 designated symptoms/signs to be diagnosed with lupus. The symptoms/signs in the diagnostic criteria include:

  1.     Malar rash
  2.     Discoid rash
  3.     Photosensitivity
  4.     Oral ulcers
  5.     Arthritis (in at least two joints)
  6.     Serositis (which is inflammation of the lining of the lungs and/or heart)
  7.     Kidney disease
  8.     Neurologic disease (usually seizures or psychosis)
  9.     Hematologic (blood) disorder, including low white blood cells, low hemoglobin (due to destruction of red blood cells), low platelets, or low lymphocytes (one of the types of white blood cells)
  10.     Abnormal immunologic laboratory results, such as anti-dsDNA, anti-SM, antiphospholipid antibody, lupus anticoagulant, or a false positive test for syphilis
  11.     Abnormal titer of ANA (antinuclear antibody)

In recent years, doctors have been able to diagnose lupus earlier because of the capacity of laboratories to detect these abnormal immune tests with much more accuracy and increased sensitivity.

For more information about lupus, please visit http://www.lupus.org/ or http://www.hopkinslupus.org.

Adahli E. Massey, MD, FACR