Spine Health & Spinal Hygiene

Many doctors/surgeons rely on the widely adopted lumbar spinal fusion. However, experts have asserted that lumbar total disc replacement or TDR should be made available and increased for treating degenerative disc disease and other spinal conditions. Individuals interested in total disc replacement, the ability to have it done, and if insurance will pay? What to know about TDR and fusion before deciding and moving forward.

Total Disc Replacement

Spinal fusion has been the traditional approach for relieving lower back pain. In this procedure, a bone graft is inserted between two or more vertebrae. This eliminates movement that causes pain or could be dangerous to the individual. Total disc replacement demands more on a technical level than spinal fusion. However, the worn-out, injured, or damaged disc is fully replaced, even a completely degenerated disc, with a metal and/or plastic one. Benefits from lumbar TDR surgery include:

• Shown to be a safe procedure with minimal complications
• Significant improvement in health and quality of life
• High rates of successful outcomes
• Mobility is preserved

Who Needs Disc Replacement?

Low back problems affect more than a third of the population. This can come from:

• Personal
• Work
• Sports
• Automobile injuries
• Aging
• All are risk factors

Fusion or Total disc replacement

Fusion reduces and eliminates motion around the affected area which also changes with the spine’s mechanics. It can also place increased stress on the surrounding segments. However, the lack of motion is to eliminate the pain. Total disc replacement does increase mobility, but it can’t fully relieve the pain.  It can relieve pain generated from the disc but not from other causes. TDR has been shown to:

• Provides motion preservation
• Reduces staying at the hospital
• Provides long-term durability
• Lower reoperation rates compared to fusion

Total disc replacement issues:

• The procedure is more time-consuming
• A lot of time making decisions
• A lot of time preparing

An example could be the patient has a narrow disc space. Looking at the X-rays of the discs above and below, the surgeon has to make sure they choose the right size. The narrow space needs to be mobilized back to a normal height that cannot be too high or too short. Finally, the surgeon has to make sure that the disc is anchored and fits properly.

Why Surgeons Still Choose Fusion?

Despite the benefits, there are reasons why surgeons still choose fusion.

• There are strict rules as to when TDR can be used. This means insurers are prone only to approve fusion procedures.
• The surgical technique is challenging. TDR surgery is a highly demanding procedure. Many doctors that have specialized in fusion for 20 years or more can be reluctant to perform the procedure.
• Complications and revision surgeries. Reoperations are sometimes necessary, but this happens in both fusion and TDR.

Individual Needs

Fortunately, most individuals with lower back problems never need total disc replacement. And those that do have severe pain/conditions are recommended to try non-invasive/surgical treatment. This ranges from:

• Chiropractic
• Physical therapy
• Massage

Imaging and lab tests will be required.

However, if an operation is necessary, ask questions about both procedures. If a surgeon insists that fusion is the only option, ask why total disc replacement is not an option?

Body Composition Testing

Protein and Weight Loss

Protein is one of three basic macronutrients found in food. Proteins are made up of smaller units called amino acids. There are 22 amino acids, with 9 of these being essential. This means the body needs them, as the body cannot produce them. These essential amino acids can be obtained by eating protein-rich foods like:

• Eggs
• Meat
• Fish
• Vegetarian/vegan options include:
• Nuts
• Seeds
• Beans
• Tofu

Generally, all the essential amino acids cannot be obtained from just one food. Therefore it is recommended to eat a variety of animal and plant-based proteins. Protein is in almost every structure and function of the body.

Antibodies

These proteins fight off any infections, bacteria, etc.

Repair, maintenance, and structural

Proteins are the building blocks of the body's muscles, bones, skin, and hair.

Hormones

Chemical messenger proteins are how cells and organs communicate. For example, Growth Hormone affects muscle gain and fat loss.

Enzymes

Not all proteins are enzymes; however, all enzymes are proteins. These proteins are catalysts or starters for chemical reactions in the body.

Transportation and storage

Some proteins carry molecules where they are needed. Like hemoglobin or the red blood cells carry oxygen to cells, then transport carbon dioxide away.

Not getting enough protein in one's diet can have serious consequences on the body's health. Without enough protein, the muscles can begin to atrophy or waste away, taking Lean Body Mass, strength, and energy away as well.

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Salzmann, Stephan N et al. “Lumbar disc replacement surgery-successes and obstacles to widespread adoption.” Current reviews in musculoskeletal medicine vol. 10,2 (2017): 153-159. doi:10.1007/s12178-017-9397-4

Hopkins overview of Lumbar TDR (for consumers) https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/lumbar-disk-replacement

“Comparison of Lumbar Total Disc Replacement With Surgical Spinal Fusion for the Treatment of Single-Level Degenerative Disc Disease: A Meta-Analysis of 5-Year Outcomes From Randomized Controlled Trials”, Zigler J, et al., Global Spine Journal, June 2018, PMC602295

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022955/

“Overview of Lumbar TDR” (for consumers); Johns Hopkins Medical Center https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/lumbar-disk-replacement

Anterior cervical discectomy and fusion (ACDF) is a procedure that treats chronic neck conditions and is the most common spinal surgery performed in the U.S. 30 percent of Americans a year experience neck pain, chronic neck pain and radiculopathy or pain that spreads out and radiates to other parts of the body, in this case down the arms.

It’s a procedure that can work wonders, but as many as two-thirds of patients continue to manage neck pain and dysfunction after ACDF. One of the best ways of managing neck pain and dysfunction is to exercise. Research shows that a prescribed exercise program right after surgery can help lessen the pain and create less dependence on medications. A 2020 study published in SPINE suggests that patients that began therapeutic exercises right away had better results than individuals that started an exercise program after the six-week checkup/examination.

What Anterior Cervical Discectomy Fusion Treats

The procedure is performed on individuals with degenerative disc disease or a bulging or herniated disc. These conditions can cause the spinal disc to place pressure on the spinal cord and nerve roots that branch out, creating:

• Numbness
• Tingling
• Pain
• Weakness in one or both arms

Most individuals that are recommended to undergo the surgery experience symptoms that don’t respond to non-surgical therapies or medication/s. A significant symptom is hand/arm weakness and arm pain that’s worse than the neck pain.

ACDF Surgery

The ACDF procedure is broken into two parts: a discectomy and a fusion. Anterior means in front and in this case it's the front of the neck that the surgeon accesses the damaged discs. In a discectomy, the surgeon removes a portion/s or all of an intervertebral disc/s to release the pressure on the nerves. The fusion part fuses the two vertebrae together. This eliminates the painful movements. A bone graft is inserted between the vertebrae at the spot where the disc was removed. The bone graft serves as a structural scaffold that the body uses to build new tissue and cause the vertebrae to grow together.

The graft can come from three sources:

• Your own bone called an autograft, this is usually a piece of bone from the pelvis just above where the front jean pocket would be.
• Bone donation called an allograft that comes from a cadaver from a bone donor bank.
• Substitute material/s like man-made plastic, ceramic, or bioresorbable compounds.

Home Exercise Program

There are those that are of the opinion to hold off on physical therapy or exercise until about six weeks post-ACDF when recovery is established. However, the study suggests it is more effective to begin a home exercise program (HEP) as soon as possible. At this time telemedicine is the replacement for in-person physical therapy sessions but works just as well. The study examined 28 individuals' outcomes over 12-months post-operation.

The participants were divided into two groups:  Standard care and Early HEP. Both groups went through the standard postoperative care, along with medication, a cervical collar or neck brace, and restrictions of certain activities. The standard care group received physical therapy referral six weeks after surgery while the early HEP group was given a home exercise program to perform during the postoperative six-weeks.

This included walking and sleeping instructions and a range of motion/strengthening exercises. A cognitive-behavioral strategy was also given to help relax. The participants would phone-conference with a physical therapist on a weekly basis. Exercises increased in difficulty every two weeks, based on the therapists' judgment. When compared to the standard care group, the early HEP group reported a reduction in short-term neck pain and were less likely to be using pain meds/opioids twelve months after their surgery.

Recovery Tips

Recovery time after ACDF surgery typically lasts about four to six weeks. If the bone graft was from the pelvis, there could be pain, soreness, and stiffness. To minimize discomfort, try not to sit or lie down for long periods. And remember to change position or take a quick short walk down the hall, to the kitchen, etc. every 20-30 minutes. If you are referred to physical therapy combine it with the home exercise program. The therapist will teach you exercises and proper form. Exercising ten minutes every day is far more effective than doing 45 minutes once a week.

Resuming normal activities gradually is crucial. No pain, no gain does not apply when recovering from ACDF surgery. Recovery exercises can feel great. However, pain and fatigue can sneak up the next day or the following week. Gradually easing back into daily activities can help avoid major setbacks. Work, shopping, house chores, childcare, and lawn care all fall into the activity category.

A recurrence of neck pain after recovery is normal. However, discomfort can be minimized by taking a few precautions.

• Use proper form when lifting
• Keep objects close to the body
• Keep the back flat as you lift
• Maintain neutral neck position
• Be aware of your posture when sitting, standing, walking, and sleeping
• Gradually increase the exercise program
• Don't overdo it
• Address underlying fear/anxiety
• Fear of generating pain can cause tension and exacerbate or even create new pain symptoms
• Stop smoking, as it has shown to impede the fusion and heighten the risk for complications

ACDF surgery can improve quality of life. Your surgeon is responsible for performing the procedure, it’s up to the individual to follow through with an exercise program and proper ergonomics for optimal results.

Neck Pain Treatment

A bone graft is defined as using bone-in spine fusion surgery. Spinal fusion's purpose is to link or weld bones together, in this case, the spinal bones. There are a variety of spinal conditions cause instability and pain:

• Degenerative disc disease
• Scoliosis
• Trauma from an auto accident, sports injury, slip, and fall accident

Spine surgeons use a bone graft to:

• Stop motion between two or more vertebrae
• Stabilize a spinal deformity
• Repair fractures of the spine 

Spinal Fusion Stimulates New Bone Growth 

A bone graft does not heal or fuse the spine instantly. Rather a bone graft sets up a foundational frame for the individual's body to generate and grow new bone. A bone graft stimulates new bone production. It is when this new bone begins to grow and solidify, that fusion takes place.

With these types of surgeries, instrumentation like screws, and rods are typically used for the beginning stabilization. But it is the actual healing of the bone that welds the vertebrae together creating long-term stability.

A bone graft can be used for structural purposes for supporting the spine, usually, this is done in place of a disc or bone that was removed. Or it can be an onlay, this means that a mass of bone fragments will grow together to stabilize the spine bridging the joint.

There are two generalized bone graft types:

• Real bone
• Substituted bone graft

Real bone can come from the patient, which is called an auto-graft or from a donor's bone, called an allograft.

The Individual's Bone or Auto-graft

An auto-graft is bone taken or harvested from the individual's body and transplanted to a specific area, in this case, the spine. An auto-graft is considered the gold standard because it is the individual's own bone, which contains:

• Bone cells
• Proteins
• Calcified matrix

These all help to stimulate the healing of the fusion. There are advantages for an auto-graft, which include a higher probability for fusion success and a lower risk for disease transmission. The only real setback for individuals of an auto-graft is the post-operative pain that usually comes with the procedure when harvesting an individuals' bone. Bone can be harvested from one of the individual's:

• Iliac crests
• Pelvic bones
• Ribs
• Spine

Bone graft harvesting creates a new set of risks. These include:

• Post-operative pain
• Nerve injury
• Surgical wound issues

Because of these risks and the possibility that the bone could be poor quality, a surgeon could decide to use another type of bone graft. When this happens a surgeon could go with what is known as a local auto-graft. This is bone harvested from the decompression itself.

These are the parts that are removed to decompress the nerves. They usually consist of bone spurs, lamina, and portions of the spinous process. These same bone pieces can be reused to assist with the fusion of the decompressed areas.

Donor Bone or Allograft

An allograft is a bone harvested from another person, usually from a tissue bank. Tissue banks harvest bone and other tissues from cadavers for medical purposes. An allograft is prepared by freezing or freeze-drying the bone or tissues. This helps limit the risk of graft rejection. Bone from an allograft does not have living bone cells and is not as effective at fusion stimulation when compared to an autograft. However, it still does work. Tissue banks:

• Screen all their donors
• Supervise bone recovery
• Test donations
• Sterilize donations
• Store for use

Look for tissue banks that are accredited by the American Association of Tissue Banks. US Food and Drug Administration has strict regulations when it comes to human cell and tissue processing. These include rules about the eligibility of donors. These guidelines/protocols help reduce the risk of tissue contamination and the spread of disease.

Bone Graft Substitute

These substitutes are man-made or are made from a manipulated version of a natural product. These alternatives are safe and can provide a solid foundation for the individual's body to grow bone. Substitutes have similar properties of human bone, which include a porous structure and proteins that stimulate healing.

Demineralized Bone Matrix - DBM

A demineralized bone matrix is an allograft that has gone through a process where the mineral content has been removed. This demineralization helps reveal bone-forming proteins like collagen, and growth factors hidden within the bone that can stimulate healing.

This procedure is often considered a bone graft extender. It is not considered a replacement. This is because its ability to fuse the human spine on its own has not been proven. DBM can be combined with the regular bone for more volume and is available in these forms:

• Chip
• Granule
• Gel
• Powder
• Putty

Ceramic-based Extenders

Ceramic-based extenders are mixed in combination with other sources of bone. This is because they consist of calcium matrix for fusion, but there are no cells or proteins to stimulate the healing process. These include:

• Calcium phosphate
• Calcium sulfate
• Bioactive glass

Ceramic-based extenders do not present a risk for disease transfer but can cause inflammation. They are available in porous and mesh forms.

Morphogenetic Protein - BMP

Different types of bone morphogenetic proteins or BMP's are used to stimulate new bone growth. These proteins are found in human bone, however, they are trace amounts. They are then produced in larger amounts through genetic engineering.

This all depends on the type of spine surgery an individual undergoes. Bone morphogenetic protein could be considered an option in promoting new bone growth along with healing fusion.

Treating Severe & Complex Sciatica Syndromes

Telemedicine Mobile App