Chiropractic + Wellness

Surgery options when back pain is becoming chronic or so severe that an individual cannot function normally and negatively affects their life. Pretty much everyone experiences back pain at some point. This is often from:

• Lifting heavy/non-heavy objects incorrectly
• Improper posture
• Twisting in an awkward way
• Overreaching
• Muscle spasms
• Physical activity the body is not used to doing

Most cases of backaches and pain go away by themselves or with conservative treatment.  But sometimes, surgery is necessary.

When Surgery Is Necessary

Acute back pain can last for days or weeks and can often resolve with physical therapy, chiropractic, and self-care. Back pain that continues for 12 weeks or longer is considered chronic. Around twenty percent of individuals who experience acute low back pain after a year begin developing chronic back pain. Doctors try to treat most back pain cases with non-surgical approaches.

• They usually begin with physical therapy/chiropractic.
• If that doesn't work, then medication is incorporated.
• However, many individuals do not want to take long-term medication, which is when surgery may be recommended.
• In most cases, surgery is a last resort.

When the pain radiates to the legs or if it is causing problems with bladder and/or bowel function, these are definite signs/symptoms that surgery is needed. If the pain/dysfunction continues after thorough and effective non-surgical treatment, surgery could be recommended to preserve the spine to improve spinal strength and function before the problem worsens, causing further injury and damage. Some of the most common and effective spine surgery options include.

Surgery Options

Microdiscectomy

Microdiscectomy is the most common back surgery in the United States. It is minimally invasive spine surgery. Microdiscectomy patients have low back pain combined with leg pain, tingling, numbness, and weakness. In between the vertebrae are the body's shock-absorbing discs. The discs can begin to bulge out, a bulging or herniated disc, and press on the surrounding nerve roots, causing pain, tingling, numbness, or weakness. A microdiscectomy removes the portions of the disc pressing on the nerve.

It is called micro because the surgeon wears specialized glasses known as loupes that act as microscopes. This is so the surgeon can see the details when they’re operating. The surgery is performed through a small incision in the middle of the back or on the affected side. Patients can go home a few hours after the surgery and return to normal activities within two weeks. The success rate is 85 - 95%, especially if the surgery is done early before the damage begins to spread out.

Laminectomy

The spinal canal contains a special lining. This is where the nerves and ligaments run through. Age, along with normal wear and tear on the body, causes the ligaments to thicken. This is when bone spurs can develop from osteoarthritis, and the discs can begin to bulge or rupture/herniate. This clogs and impinges the space where the nerves should easily flow through. This narrowing is called spinal stenosis. A laminectomy opens up the space relieving the compression/pressure. The procedure requires removing part of the back of a vertebra called the lamina. This enlarges the spinal canal and relieves the pressure on the nerves. The procedure is done through a small incision in the middle of the back but can also be done through a minimal incision. Leg pain improves after surgery. A traditional incision full recovery takes 6 to 12 weeks. The success rate is around 85 percent.

Spinal Fusion

A spinal fusion joins/fuses two or more bones in the spine. This is done when an individual has severe compression of the nerves, severe instability, or spinal revision surgery. A fusion can help stabilize spinal fractures. Other reasons for a spinal fusion are spine deformity, cancer of the spine, and sometimes used for intractable pain. A fusion stabilizes the spine with screws and rods. The disc causing the compression is replaced with a fusion device and bone graft. The surgery is often performed in combination with a laminectomy. Recovery and returning to activities can take around 3-4 months after the procedure. The success rate is 85-90% with pain improvement.

Kyphoplasty

Spinal compression fractures are common in individuals with osteoporosis. When they happen, the pain can be so intense that braces and medication don't help. Kyphoplasty can bring pain relief. It can be performed by a pain management doctor, interventional radiologist, or surgeon in an outpatient X-ray facility and operating room. The procedure involves conscious sedation, sometimes accompanied by general anesthesia. A small instrument is inserted into the vertebra, and a balloon is inflated to make room for bone cement. After the bone cement is injected, patients can go home within a few hours. The success rate is around 85%, and recovery time could be several days.

Disc Replacement

This is a procedure that can replace spinal fusion for certain cases. A disc replacement can be done in the lumbar/low back or the cervical/neck spine. This procedure is performed to treat a pinched nerve and/or spinal cord compression. The injured/damaged disc is removed and is replaced with an artificial disc. The device allows for motion, whereas fusion procedures fuse the bones to stabilize and immobilize the area. Disc replacement is recommended for younger patients that don't have serious arthritis. This is because they still have mobility. If significant arthritis is present, the patient could experience more pain and require spinal fusion. Recovery takes around six weeks. Intense physical activity is off-limits for two or three weeks after the initial recovery period. The success rate is more than 90%.

Anterior Cervical Discectomy and Fusion - ACDF

This is a common neck/cervical spine procedure. This surgery is for pain relief, weakness, tingling, and numbness of the arms caused by a pinched nerve or stenosis. The damaged disc is removed through a small incision in the side of the front of the neck. The disc is replaced with a bone graft or specialized spacer and a small plate with screws. This is to stabilize the spine. It is highly effective in relieving pain and in preventing neurological decline from spinal cord compression. Recovery time is around 12 weeks before a full return to normal activities. However, individuals report feeling better after two weeks.

Back Surgery Options

The majority of cases involving back pain get better on their own or with conservative treatment. But if an individual cannot find relief, there are safe and effective surgery options that can help.

Body Composition

When The Immune System Activates

When the body gets sick from a bacterial infection, virus, etc., the body’s defense system activates, causing inflammation. This immune response serves as the first wave of defense against foreign invaders. The infected area becomes red and swollen from increased blood flow. For example, when the nose gets red from a cold, this is inflammation. The reaction is caused by white blood cells known as macrophages, and the proteins they emit called cytokines encourage inflammation. Inflammation that’s triggered by the immune system is normally a good thing. It means the body is releasing a proper amount of hormones and proteins. These activate the white blood cells to start the healing process and work to fight the infection.

References

Low Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet

A review of complication rates for Anterior Cervical Diskectomy and Fusion (ACDF). Surg Neurol Int. 2019. https://pubmed.ncbi.nlm.nih.gov/31528438/

Rheumatology Advisor. (2017.) “Back Pain.” https://www.rheumatologyadvisor.com/home/decision-support-in-medicine/rheumatology/back-pain/

If you want to reduce the number of opioid prescriptions and pills being used, and potentially misused, you need alternative pain management. And chiropractors say that’s what they’ve been providing for decades.

“It gives people options, and that’s probably the most important thing right now is to give people options for treatment,” Dr. Mark Stagnone, president of the New Hampshire Chiropractic Association said.

At its annual meeting, the association is pointing to a trio of recent studies showing that chiropractic care cuts down on the use of opiate pain medicines.

In one of the studies, a former Dartmouth doctor analyzed 33,000 cases of lower back pain in a New Hampshire database.

“His preliminary research is indicating that there’s about a 56-57 percent reduction in opioid use when chiropractic care has been utilized in a patients treatment,” Stagnone said.

James Vara, the governor’s adviser on addiction and behavorial health, said the state needs more alternative pain management.

“It becomes a question of what insurance covers it and how long they cover it for, and that’s certainly something I’ve looked at and will continue to,” said Vara.

THE CURRENT INSURANCE MODEL PUTS PATIENTS ON A PATH TO PRESCRIPTION DRUGS

“The problem that it produces is that the average individual who’s trying to treat a condition is faced with paying a high co-pay to visit a chiropractor or paying a considerably lower one to see a primary care physician,” Stagnone said.

Changing that dynamic will require legislation that has failed in the past. But chiropractors said in this ongoing addiction crisis, it’s time for adjustment.

Chiropractic care is covered under the New Hampshire Health Protection program, or expanded Medicaid. And if the program lapses, so does that coverage.

PAINKILLERS SOMETIMES INCREASE CHRONIC PAIN

We’re facing an opioid addiction crisis in America. Opioid (narcotic) pain medications killed an estimated 14,000 people in the U.S. in 2014 through overdose. A further 14,000 people overdosed on heroin, another opioid that many people turn to when they can’t access prescription painkillers.

See Narcotic Pain Medications


Opioid painkillers like hydrocodone can trigger dependency and increased sensitivity to pain.

See Pain Killer Addiction Treatment
 

This epidemic is why physicians and pharmacists are increasingly raising the bar on who can receive opioid medications, how much, and for how long. It’s not just the addiction risk that calls for caution when using opioids to treat chronic pain though—long-term use of opioids can actually make pain worse.

See Opioid Medication Potential Risks and Complications

PHYSICAL IMPACT OF PAINKILLERS

Becoming addicted to pain medication is a disease. This is because these painkillers (oxycodone, hydrocodone, methadone, fentanyl) cause a change in your brain chemistry that is not under your control.

Most people who take opioids for more than 2 to 4 weeks will develop a tolerance to the medication. Tolerance means your body may need an increased dosage to feel the same effect. Opioid tolerance can cause withdrawal symptoms when the medication is stopped. This is a natural process, and it is not to be confused with addiction.

See Rapid Opiate Detoxification Treatment

In his recent blog on the subject, Dr. Ullrich explains: “Pain medication addiction is a more complicated process. It involves manipulative behavior to obtain narcotic medications and a refusal to discontinue a medication even though it is no longer being used for a medical purpose. Some, including those at significant risk of overdosing, will go to multiple doctors to get medications.”

For those who are addicted to opioid medications, a detoxification program is often needed. Painkiller addiction is a chemical, physical disease, one that requires expert medical treatment in a safe, humane environment.

See Pain Killer Addiction Treatment

PAINKILLERS MAY INCREASE PAIN

Most people know that painkillers can be addictive, but they don’t know that taking opioids over a long period of time may in fact increase a patient’s sensitivity to pain (hyperalgesia). This happens because long-term use of opiate painkillers causes a decrease in your ability to tolerate pain and an increase in sensitivity to pain. In fact, people taking opioids long term may keep having pain, or may see their pain increase, long after the original cause of pain has healed.

See Chronic Pain As a Disease: Why Does It Still Hurt?

Stopping opioid use can solve this problem—but it may not seem as if the pain is gone at first, because the discomfort of withdrawal can mimic the original pain. Dependency is not easy to deal with, but it shouldn’t be an excuse to stay on the opioid medication and raise the risk for addiction. This is why physicians are encouraged to only prescribe opioids for short durations and be cautious when using them to treat chronic pain.

Since long-term use of opioid painkillers is a risky option for controlling chronic pain, patients are often advised to focus on other safe, proven methods for managing chronic pain, such as:

Exercise to maintain motion and release endorphins
Cognitive therapy to develop coping techniques
Relaxation and meditation techniques to distract the brain from pain
Manual (massage) or topical (heat or cold) therapies
Other pain medications that are lower risk or non-habit forming

LEARN MORE:

Modern Theories of Chronic Pain

Medications for Back Pain and Neck Pain

SIX THINGS EVERY CHIROPRACTOR SHOULD KNOW ABOUT OPIOIDS

Men health concept. Portrait of 50s mature Asian man reading the label on bottle medicine, sitting on sofa at home.
 

An increase in addictions and deaths due to opioids has raised significant concern and media attention. We offer this brief overview on this important public health problem for the practicing chiropractor.

1. WHAT ARE OPIOIDS?

Opioid medications are prescribed to reduce pain; however, they are addictive and can be dangerous. Although some suggest there is “no safe dose” for opioids, these drugs may be helpful for people with severe pain, such as those experiencing pain from cancer. However, over the past several decades, more patients have been prescribed opioids for musculoskeletal pain, such as back or neck pain, instead of being provided with nondrug therapies.

As with any drug, opioids have side effects and may “adversely affect respiratory, gastrointestinal, musculoskeletal, cardiovascular, immune, endocrine, and central nervous systems.”1  As the dose increases, the risks for overdose and health concerns also increase, including “fractures, addiction, intestinal blockages, and sedation.”1 If too high a dose is consumed or if opioids are taken with certain other drugs or alcohol, death may result.

 

2. WHY IS OPIOID USE / OVERUSE PROBLEMATIC?

Since 1999, prescription opioid sales have increased fourfold, along with a surge in the use of opioids as a first line for pain management, rather than only for severe cancer-related pain. This trend has led to burgeoning opioid prescribing in the U.S.:2

 One in five people with non-cancer pain have been prescribed opioids.
 More than 165,000 prescription opioid-related deaths occurred between 1999 and 2014.
 An estimated 2 million people were addicted to opioids as of 2014.
 

3. WHO IS ADDRESSING THIS HEALTH CRISIS?

Currently, many professions are seeking ways to address this national epidemic. The medical profession has launched various initiatives to help medical doctors (MDs) reduce prescriptions. These include an initiative to remove pain as the 5th vital sign, and promoting guidelines for when to prescribe and how to better manage patients in pain without the use of opioids.

The Centers for Disease Control and Prevention (CDC) has released guidelines to curb opioid prescriptions, with the following categories of recommendations to those who prescribe opioids: 1) determine when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, discontinuation, and assessing risk; and 3) addressing harms of opioid use.

In addition to these efforts, even more focus is needed to assist people who seek help for pain and to provide them with nonpharmacological alternatives.

 

4. WHAT CAN DOCTORS OF CHIROPRACTIC DO?

Chiropractic care can be part of the solution. DCs can work with other health care providers and support policy to offer alternatives to opioids for addressing patients in pain, especially chronic non-cancer pain.

Although there are no large trials comparing outcomes of chiropractic care to opioids, we do know opioid use is associated with worse functioning in back pain patients at six-month follow-up3  and greater disability;4  and that injured workers whose first health care visit is to a DC have better outcomes.5  We also know that the per-capita supply of DCs and higher use of manipulative therapy is associated with lower rates of opioid prescriptions among Medicare recipients.6

All this suggests chiropractic care may help reduce the use of and need for opioid prescriptions for back pain sufferers; and may play an important role in reducing the opioid epidemic by helping to prevent patients from ever getting an opioid prescription in the first place.

Important resources DCs should be aware of include:

 Never Only Opioids: www.painsproject.org/ policy-brief-never-opioids/
 Chiropractic: A Safer Strategy Than Opioids: www.f4cp. com/f4cp_opioid_white_paper.pdf
 Centers for Disease Control and Prevention (CDC): Opioid Overdose: www.cdc.gov/drugoverdose/ Six Things Every Chiropractor Should Know About Opioids By Claire Johnson, DC, MSEd, PhD, Bart N. Green, DC, MSEd, PhD and Michael Haneline, DC, MPH Reprinted with permission from Dynamic Chiropractic, Sept. 1, 2016, Vol. 34, Issue 15 (www.dynamicchiropractic.com/digital/index.php?i=1220&r=t#19)
 

5. WHAT CAN WE DO IF A PATIENT IS ALREADY TAKING OPIOIDS?

Most chiropractors take a history and ask patients what medications they are taking. The first step is to recognize that the following are opioid-class drugs: hydrocodone (Vicodin), ultram (Tramadol), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza) and codeine.7

Once we know a patient is taking opioids, we must first seek to understand the situation before we provide education.

Questions we can ask include:

 For what condition is the patient taking the medication?
 How long has the patient been taking opioids and at what daily dose?
 Who is the provider watching over their prescription? Is more than one provider prescribing opioids?
 When was the last time the patient saw the prescribing physician and when is the next appointment?
 Does the patient have any safety issues? For example, does the patient operate machinery? Is the patient experiencing side effects such as “sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, or respiratory depression”?8
 What is the patient’s level of function? Are there any psychological flags or addictive behaviors?
 Is the patient taking any other substances or drugs that may have deadly interactions, such as alcohol, benzodiazepines and/or other opioids?
As chiropractors, we can discuss treatment goals, such as reasonable functional activity; and pain goals with and without medication. We also can discuss potential adverse events, including the risks for side effects, addiction and death.

We can inform patients of other dangers they may not be aware of, such as the deadly combination of opioids when combined with other drugs that depress CNS activity (e.g., alcohol or drugs for anxiety such as benzodiazepines). We can encourage patients to contact the prescribing provider to discuss reducing and stopping opioid use, and to ask for safer alternatives for pain control, such as chiropractic care, physical therapy, acupuncture and mind-body methods. If a patient is already addicted, we can encourage the patient to seek a specialist provider and addiction care program. (Note that some patients may need to remain on opioids, such as for cancer pain or end-of-life care.)

Most importantly, we can work with the patient and their prescribing provider to offer them nonpharmacological care to help reduce their pain and help them reach their functional goals.

 

6. HOW CAN WE COLLABORATE MORE ON SOLUTIONS?

As DCs, we can work more closely with local MDs and discuss better ways to collaborate concerning patients with pain. Remember that MDs are not the enemy, but are an essential component of the solution to this epidemic. Most MDs are also extremely concerned about the opioid epidemic, and are looking for efficient and cost-effective ways of helping their patients. We should remain professional when speaking about MDs with our patients, as our patients likely have good relations with them.

We can be part of the safety net to help reduce the number of people who become addicted or die from overdose. As we work with other health care professionals and our patients, we can remind them that the first recommendation per the CDC’s Guideline for Prescribing Opioids for Chronic Pain is “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.”9  Thus, through collaboration, the chiropractic profession can be a part of the solution.