2015 New Mexico Workers Comp Annual Meeting

The 2015 Annual New Mexico Workers Comp meeting took place at the Ysleta resort in Albuquerque on May 13-15th. I was given an opportunity to discuss causation issues re: neck pain on May 14th. My talk titled “Neck pain in the work environment” discussed workers comp issues in regards to chronic and acute pain and addressing causation.

The concepts of temporal relationships, dose response and mechanistic plausibility were discussed. A literature review was also presented.

The Workers Comp talks and conference allows for meaningful interaction between MD’s, Lawyers, Insurance Companies, Physical Therapists and Nurses; regarding Workers Comp injuries. The sharing of information on best practices & methodology allows for better coordinated care of the injured worker.

Paul Saiz, MD

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Smokers may have higher incidence of swallowing issues after Anterior Neck Surgery than non-smokers

Cervical fusions typically involve approaching the neck from the front. This approach includes mobilization of the esophagus and trachea which always involves some amount of dysphagia (problems swallowing). Dysphagia can last anywhere from two weeks to sometimes multiple months or years. A general rule of thumb is that the more levels operated on, the more likely the patient is to have dysphagia. Other risk factors for swallowing issues post op include prior surgery, length of surgical procedure and preoperative swallowing complaints

A recent study presented at the Cervical Spine Research Society Annual Meeting by Erik Olsson, MD et al found that smoking can be a risk factor for dysphagia. “Their (Smokers) symptoms when they experienced dysphagia, were more severe when compared to non-smokers or former smokers.” The authors identified prior surgery and smoking as risk factors for long term swallowing problems.

Smoking has always been associated with higher rates of nonunion (inability to grow new bone) in spine surgery. This study by Olsson and associates, sheds light on the increased risk of long term dysphagia in smokers.

Prior to any spine surgery it is important to counsel the patient as to the increased risks associated with smoking and how smoking can affect surgical outcomes. Ultimately, it must be the patient who decides not to smoke.

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Neck surgery can be more cost effective and just as safe at Ambulatory Surgical Center (ASC) vs Hospital

A recent study presented at the Congress of Neurological Surgeons (CNS) in Boston showed that 1 & 2 level neck fusions can be performed as safely and cheaper than the same surgery performed at a hospital. Matthew J McGirt, MD presented the findings at the annual CNS meeting and along with his co-investigator also received The Samuel Hassenbusch Young Neurosurgeon Award at the meeting for the research.

The study compared two groups of patients who underwent 1 and 2 level anterior neck surgeries (ACD&F) at an ASC vs a hospital. They found the complication rates, return to work rates and outcomes at 3 months were equal. More importantly, the surgeries performed at an ASC were on average $7,000 cheaper. “This is a cost saving advancement in ACD&F surgery. From a patient, payer, purchaser, and societal perspective, the ASC setting offers superior value and can lead to cost savings of over $7,000 per patient.” adds Dr McGirt.

Las Cruces Orthopedic Associates (LCOA) and Las Cruces Surgical Center (LCSC) have been performing outpatient anterior neck surgery since 2009. Our goal has always been to provide the most efficient and cost effective care possible. This important paper adds more evidence to the effectiveness of outpatient, ASC based surgical care.

Paul Saiz, MDACD&F C5-6

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Did you know?

Las Cruces Orthopedic Associates would like to congratulate Dr Paul Saiz, for being the first physician in Southern New Mexico and the El Paso area to implant the new Medtronic low profile (LP) Prestige Cervical Disc Replacement.

Disc replacement, in certain patients, can replace neck fusion for neck and arm pain while preserving motion above and below the area of surgery. Single level disc replacements can be performed as outpatient surgery and is one of the many spine surgeries performed by Paul Saiz, MD in an outpatient setting.

Las Cruces Orthopedic Associates (LCOA)

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Why do complications happen?

Once a back or neck surgery decision is made; a consent form is signed detailing risks and benefits of surgery. Typical benefits from surgery include a decrease in back-neck &/ or leg-arm pain, more motion, less reliance on medications and improved function.

The downside of surgery involves complications. This typically involves unexpected negative results such as infection, nerve injury, failure of screws and continued pain. A common question I am asked is “Why did this happen?” The answer is as varied as the complications. The simplest answer is that unexpected results always occur, a certain percentage of the time. For example, if infection happens 2-4% of the time and you perform 100 surgeries; that is 2-4 infections.

We also know that certain risk factors increase complication rates. Obesity has been shown to increase the risk of infection, failure of hardware, blood clots and non-union. Smoking has been shown to increase chances of non-union, wound breakdown, infection and lung issues with anesthesia. Interestingly, people who smoke or are obese are more likely to have back and leg problems. For instance, smokers are 2X more likely to have low back surgery and 2.5X more likely to have neck surgery.

Other risk factors for complications include prior back &/ or neck surgery, workers comp injury, failure to follow post op directions and narcotic abuse among others. We have not even brought up the risks associated with anesthesia & pain control which are separate from the surgery. This includes heart issues, constipation, lung problems, uncontrolled diabetes and blood clots. A general rule of thumb is that the sicker you are, the more likely you are to have a complication.

The effect of prior surgery is often underestimated. Having had anatomy disturbed which includes nerves uncovered or spine levels fused; increases the complexity of the surgery and alters surgeon decision making. Risks of unexpected injury to nerves or blood vessels, infection, failure of screws or cages, lack of pain improvement, and longer recovery times are all more frequent after repeat surgery. Many surgeons will not operate on patients with prior surgery because of the above reasons.

Overall, back and neck surgery has become more effective over time. However, complications still happen. As a surgeon, my job is to treat the individual patient and make decisions based on my training and twelve years experience. If an unexpected event does happen, I will do everything I can to fix the problem. Some complications cannot be avoided and fault belongs to no one. More importantly, a motivated and positive patient helps enormously in overcoming obstacles and achieving a successful outcome.

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Is Spinal Fusion bad?

Simply put, a spine fusion is where the body attempts to grow new bone in an area that had no prior bone. Surgeons typically perform fusion surgery for instability of the spine, fractures, tumors, infections, painful discs. Cages (spacers), screws, plates and bone-like material help the body create/ grow new bone. Instrumentation is used to stabilize the spine so the fusion process can occur…similar to a cast for a broken ankle. The steps required to grow new bone can sometimes take 5-6 months or longer.

So then, why is fusion bad? Prior to the technology explosion in Spine (mid to late 90’s) and the use of MRI, identifying where pain was coming from was elusive. Even today, surgeons encounter difficulty in trying to figure out exactly what hurts. Certain body parts such as discs (shock absorbers in between the spine bones) can cause leg, butt or back pain. We often encounter people who have had spine surgery and experienced bad results. Unfortunately, we hear about bad results more than we hear about good results. Fusion surgery is not for everyone. In cases where you are unsure of where the majority of the pain is coming from….fusion is a poor option. However, in selected cases, fusion can improve activity levels and decrease pain.

One thing fusion is not, is a cure. As surgeons we are immobilizing a segment of the spine that was intended to be a moving part. The price of a fusion is that the other moving parts of the spine compensate and now work harder. This additional work means that there is an increased risk of other levels wearing out sooner. Think of your car, if you remove 1 shock absorber and are left with 3…how long will they last? Fusion is an attempt to improve quality of life. The surgery cannot make a patient pain free and feeling as if they never had any spine problems. Outside of fractures, tumors or infections….most spine surgery is a “last option” after having tried non surgical treatments.

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When NO surgery is a good thing?

Oftentimes, when evaluating a patient I offer my opinion that they are not a surgical candidate. This opinion comes after a thoughtful review of the history, physical exam, imaging findings and the patient’s expectations. Sometimes, no good surgical options are available.

An important concept to learn is that surgical procedures are focused on decreasing pain and/ or minimizing nerve injury. If a patient has complaints or findings that a surgery cannot improve upon; then the best option is NO surgery.

Another time surgery may not be the best option is when the risks of the procedure outweigh the benefits. Typically, the older or sicker we are the more risk associated with anesthesia and the trauma of surgery. Some procedures may take 2-6 hours (depending on the complexity of the case) which increases blood loss, risk of infection, anesthetic risks and post op complications.

Ultimately, both the surgeon and patient want the best outcome possible. If surgery cannot deliver a reasonable outcome, then non-operative treatment makes the most sense. When I get a disappointed look from the patient during the conversation; I mention that as a surgeon I enjoy operating BUT I appreciate a good outcome even more.

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