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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LCOA congratulates Paul Saiz, MD

Las Cruces Orthopedic Associates would like to congratulate Dr Paul Saiz for his latest article published in the July/ August issue of Spineline. His article is entitled Lumbar Laminectomy Code Review and addresses proper coding of lumbar spine decompression procedures. Spineline is a bimonthly journal addressing all issues spine related and is published by the North American Spine Society (NASS). NASS is a multi-disciplinary medical society consisting of Orthopedic Surgeons, Neurosurgeons, Physical Medicine & Rehabilitation and Pain Management physicians.

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Neymar and His Broken Back

Anybody watching the World Cup or familiar with soccer has heard of Neymar; the star of the Brazilian National Soccer team and plays his club ball next to Messi at Barcelona. During a game against Columbia in the Quarterfinals of the World Cup, Neymar was involved in an aerial challenge with a Columbian player that involved a knee to the lumbar spine of the Brazilian. Afterwards, Neymar was taken on a stretcher to the hospital where he was diagnosed with a Lumbar 3 vertebrae fracture.

Amid all the reports of potential paralysis, the good news is that neurologic injury is extremely rare from this type of injury. The Columbian player made contact with his knee against the muscles of the low back of Neymar.  Some of the forces  imparted by the blow could have caused a fracture or in combination with muscular contraction caused a piece of the spine bone (Vertebra) to break (fracture). The most common areas of the spine to break would be the Spinous Processes or the Transverse processes. These bony prominences serve as muscle attachment points and do not have a weight bearing responsibility. In other words, even with a fracture, the Spine is stable and the patient can walk and do activities as long as pain is under control.

Typically, with this group of stable, non-surgical injuries, pain control is the first step which involves bracing or a brief period of immobilization. Similar to rib fractures, time will eventually heal the injury and activity as tolerated is instituted once the patient feels better (typically 2-4 weeks). On average, fracture healing requires 6 weeks and then the patient can begin to resume normal activities. The long term prognosis from these injuries is good and most people are back to full activity within 3-6 months.

The good news for Neymar is that he should expect a full recovery with no limitations over the next 3-4 months. The bad news for Brazil is that there best player won’t be on the field for the World Cup.

Paul Saiz, MD

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About Sacro-Iliac Pain

Dr. Paul Saiz is an expert on orthopedic injuries of the spine. The owner of Las Cruces Orthopedic Associates, Paul Saiz, MD, is the author of numerous articles regarding spinal ailments and musculoskeletal disorders.

The sacro-iliac joint is the part of the body responsible for transferring weight between the legs and the back and torso. Stress on this joint can be as much as two to three times greater than an individual’s body weight, which can cause a great deal of pain. In fact, the SI joint causes an estimated 20 to 25 percent of reported cases of back pain. In addition, the SI joint is thought to be the source of pain among 50 percent of all failed back surgeries.

There are a number of ways to treat SI pain, the most common being stabilization belts, anti-inflammatory injections, and physical therapy. In recent years, new technology has been developed to fuse, or immobilize, the SI joint through surgery. Over 25,000 patients have received the procedure, with minimal complications. And although not every patient requires surgery, those with chronic sacroiliac pain may want to consider surgery of the SI joint as an option.

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Minimally Invasive Surgery Option for Sacroiliac Joint Pain

Paul Saiz, MD, is the only fellowship-trained spine and tumor surgeon in New Mexico. As the owner of Las Cruces Orthopedic Associates in Las Cruces, New Mexico, Dr. Paul Saiz is a highly respected orthopedic spine surgeon, having earned many faculty nominations and recognition for his articles on topics pertaining to back and neck conditions, such as sacroiliac (SI) joint pain.

Responsible for transforming weight back and forth from the legs to the lower back, the sacroiliac (SI) joint has often been overlooked due to the fact that, for many years, there was a lack of information on how the SI joint can cause pain. Presently, the SI joint is recognized as as a potential pain generator in regards to lower back pain. For chronic pain originating in the SI joint, surgery is a valid treatment option. Today’s minimally invasive surgery treats the lumber spine and SI joint with a combination of technology and tissue sparing techniques, reducing recovery time to outpatient surgery or 1-2 days as an inpatient. However, not all insurance plans will pay for these surgeries to be done as an outpatient. In addition, how healthy patients are can determine whether a procedure can be done as an inpatient or outpatient.

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