Working with the Surgeon

I would like to discuss quickly how to co-manage spine case with a surgeon, and in this case I am using an orthopedic surgeon. 

The reason I like the orthopedic surgeon is that they come from a stand point of biomechanics.  And I am not talking about an orthopedic surgeon that dabbles in spine, they have to have done a spine fellowship and that means that they are typically working with neurosurgeons. 

When somebody’s spine is injured there are always two components, there is a biomechanical component and there is an anatomical component.  So an example of a biomechanical component would be a rotated L5, loss of lumbar lordosis, loss of cervical lordosis or maybe a lateral curvature etc.  So there is both a structural and mechanical change.  An example of anatomical problem would be a 5-mm lumbar disc herniation centrally located, a fracture, a grade 2 ligament sprain with a 4-mm anterolisthesis at C5/C6.  So there is an anatomical issue on top of a mechanical issue.  So when you are looking to manage the patient, you are not treating that patient to simply see if they fail conservative care so that the surgeon can correct the anatomical lesion.  You are trying to biomechanically stabilize that patient so if or when there needs to be an anatomical intervention like surgery the patient, is in the best biomechanical state to accept that treatment. 

In the beginning you are stabilizing the rotational components of the vertebral bodies, the sagittal curves and the pelvic incidence angle. I will be getting more into pelvic incidence in another consultation.  When the patient goes to see the surgeon, if they have to ultimately remove the disc, we can be sure that the patient is going to be fused in a biomechanically stable position.  This is in contrast to the patient having surgery too early and now they are being fused in a biomechanically compromised position, and that is the one biggest reasons for failed back surgeries and continued chronic pain.  It is not that the surgery did not work it is just that they fused them in a biomechanically compromised position and now you cannot “unwind” that because it is fused. 

Once the patient has surgery and in this example were using a fusion, you want that patient back, once the hardware is set and it is healed that patient needs to come back to your practice for a biomechanical assessment.  So I would reissue x-rays, I would look at the sagittal curvature, I would look at the pelvic incidence angle and I would look at flexion-extension views to see if there is any anterolisthesis above or below the fusion site.  The chiropractor now can come in and re-stabilize any biomechanical abnormalities. That patient then gets put on a “health maintenance plan” so that you can maintain their range of motion and their function.  Remember, biomechanical interventions occur before and after surgery, surgery is just something in between that corrects the anatomical deficit if there is one. 

Ask you surgeon the following question “When you are fusing a patient’s spine, how do you know they are not in a biomechanically compromised position segmentally” – 95% of the time they will say “I don’t”