Keith roberts collage

Two years ago, Keith Roberts was relocating his office. He began to feel immediate pain in his lower back after lifting a table. The pain became progressively worse from that point. His doctor told him it was just a sprain, but he soon learned more about his diagnosis.  After a regimen including rest and anti-inflammatory medications, he didn’t get better. “I’m a fairly active person and I knew there was something more to this,” he said. His first doctor ordered an MRI and the scan revealed a herniated disc. “My wife and I did a lot of research and we decided to try Texas Back Institute,” Keith said. “It was the best thing we’ve ever done.”

Keith made an appointment with Dr. Jessica Shellock and hasn’t looked back since. Texas Back Institute helped him navigate through the sometimes laborious paperwork involved with a worker’s compensation claim. “Without Dr. Shellock’s medical expertise and Tonya’s help with everything, I have no idea where I would be today.”  The Tonya he is referring to is Dr. Shellock’s medical assistant, Tonya Edwards. Medical Assistants are imperative to the delivery of healthcare for the providers at Texas Back Institute. They help obtain information about the patient including vital signs, medication, and their medical history.  They also assist the patient with future testing and appointments. “If it wasn’t for them, I wouldn’t have been able to get the surgery that I really needed to get better.”

After failing to respond to conservative treatment and without sustained relief following a microdiscectomy, Keith ultimately underwent a L5-S1 fusion in November 2012 with Dr. Shellock.  It was after progressive worsening of his symptoms at this point that I recommended the fusion,” said Dr. Shellock.  “He has done fantastic. “

He took three months off of work to recover properly and is now attending outpatient physical therapy sessions at TBI. He went from being very active to no activity and is now making a comeback. In April, he was able to complete his first 6-mile bike ride and this summer, his plans include a 12-mile hike in the Ozarks with his wife.  He and his wife are avid photographers and have donated art work for Dr. Shellock’s patient rooms.

“It’s amazing to go from being able to walk less than a half a mile and having so much pain to this,” said Keith. “I missed out on 2 years of my life and I would be missing more if it weren’t for Dr. Shellock.”

Graduation

With the sound of “Pomp and Circumstance” ringing in their ears, the graduates of 2013 will be marching up to the stage and on to their future. There is a sense of accomplishment, pride and even relief at graduations because the participants feel they have completed something important. Texas Back Institute congratulates every graduate!

With graduations, it seems as if something has concluded, when in fact the term “commencement” suggests a beginning. This idea of “conclusion vs. commencement” has of course been employed by more than one valedictorian in their one, final address to their esteemed classmates.

Traditions of Graduation

This is the time of year when seniors in high school and college who have completed their courses successfully are awarded diplomas. This tradition goes back to the 11th Century when medieval colleges in Paris and Bologna reportedly began this practice.

Over the centuries, the traditions have evolved and changed, but many have remained remarkably similar to the original ceremonies. The students, who were known as apprentices in these early graduations, learned skills from the masters of the crafts and to note this accomplishment, they were give a “testimonial of skill,” now known as a degree.

The song that most of us associate with graduation ceremonies – “Pomp and Circumstance” – is a relatively new wrinkle on this ancient celebration. It was written by Sir Edward Elgar and first performed in Liverpool, England in 1901. Its melody, a combination of solemnity and dogged determination, is the perfect accompaniment to purposeful marching of the soon-to-be graduates.

Another interesting graduation ceremony tradition involves the attire of the honored matriculates. The cap and gown, which is worn by students and (in some cases) faculty, was once called a “hood” and this is believed to be dated back to ancient Celtic Groups. Capes and hoods were worn by the Druid priests to symbolize their higher intelligence.

What’s Next?   

After the music finally stops, the mortar boards are tossed and the diplomas are filed away, what happens then? The graduate – of high school or college – must commence the next stage of his or her life. For many, this means getting more education and beginning the process of deciphering how to spend the rest of one’s life.

Texas Back Institute is internationally known for its state of the art treatment of neck and back injuries, back pain, scoliosis, artificial disc replacement, occupational and sports medicine and its exemplary physical therapy practice. However, for the past 27 years, Texas Back Institute, led by one of the organization’s founding partners, Dr. Richard Guyer, has offered a select group of medical school residents a remarkable opportunity – a one-year fellowship to focus on spine surgery.

To anyone talking with Dr. Guyer about the Texas Back Institute fellowship program, it is immediately obvious that he is just as enthusiastic as the young doctors who are chosen for the program. Much like the master craftsmen who trained the apprentices in earliest institutions of learning, there is a commitment to teaching these future surgeons that goes beyond cursory. The doctors who emerge from this program are changed forever.

With his interest in teaching, we thought Dr. Guyer might be a good source of advice for graduates of any level – high school, college or graduate school. Here is that conversation.

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What areas of medicine will be in high-demand in the coming years?

There are so many opportunities in medicine, especially if a young man or woman is interested in computers, science or engineering. We’ve all read that more and more kids are interested in business, finance or high technology, but the opportunities in medicine are exploding. For example, the latest high tech robotic surgery equipment is still directed by a human who is a trained physician and many of the best practitioners of this specialty were video gamers when they were kids. Genetic engineering is going to be a very hot area of medicine in the coming years and this specialty requires a very analytical mind which many youngsters who are good at math and science possess.

If someone is graduating from college and accepted to medical school, what types of specialization might they consider for spine surgery or other specialties offered by Texas Back Institute?

When I first started in medicine, young physicians would spend a couple of years in medical school before they decided which specialty interested them. Things have changed a lot since then and now that decision is often made when they are in college. The types of procedures we do at Texas Back Institute involve a wide range of medicine. We handle spine surgery for both children and adults. Our doctors deal with trauma surgery which would be required for automobile accidents and other accidents. We treat injuries that are the result of aging – wear and tear damage. We also have quite a few sports injuries that our physicians treat. So you can see there is a wide range of opportunities just in the spine area.

How did the Texas Back Institute Fellowship program come about?

I’ve found that when you teach students, you learn as much as they do and I loved teaching. In the mid 80s, I approached my colleagues here and shared my passion about teaching. I mentioned that I’d really like to build a fellowship program here for residents who wanted to specialize in spine surgery. Since our beginning in 1986, we have trained more than 100 fellows and I have been the chairman of this program for 27 years. This keeps me young and sharp! We work hard at sharing the latest research and techniques about spine surgery for these young doctors and for everyone on the Texas Back Institute staff it is very gratifying when that light bulb comes on over the head of these talented young people.

How does the TBI fellowship program work?

These doctors have been through medical school and have completed their residency program. They find us through the network of former TBI fellows and through the American Academy of Orthopedic Medicine. Once they are accepted to the fellowship program, they work with all of the surgeons on our staff. They get hands-on training in deformative and degenerative medical issues, trauma, tumors and disc replacement surgery.

What are the criteria that Texas Back Institute uses to recruit new physicians to the practice? Does completing your fellowship help in gaining a position?

The last 4 or 5 physicians that we have hired have gone through the Texas Back Institute Fellowship program, so that suggests that there is an advantage of going through this training. When we recruit new doctors for our team, we look for a young woman or man with a high degree of intelligence, an excellent bedside manner, his or her ability to synthesize a large amount of information and apply it to treatment and most importantly we look for integrity.

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From Left to Right: Dr. Rey Bosita, Dr. Rajesh Arakal, Dr. Jack Zigler, Dr. Jason Sparks (Fellow), Dr. Richard Guyer, Dr. Ralph Rashbaum, Dr. Troy Morrison (Fellow), Dr. Kirill Ilalov (Fellow), Dr. Michael Duffy, Dr. Kenny Edwards (Fellow), Dr. Andrew Block, and Dr. Dan Bradley.

Successfully completing a course of study and celebrating this accomplishment with friends and family is one of life’s great pleasures. As speakers who are chosen to impart wisdom to a group of graduates are fond of noting, this ceremony is not the conclusion, it is the beginning. Congratulations to every graduate and their families. Now, let’s get busy!

Update from Ethiopia

March 27, 2013

Surgery on that cutey was Sunday. She is doing great. It took a few days to coax another smile, but all is well. I have a lot of great cases to show when I get back.

Ted Belanger

Facet Joint Pain

Recently Spine-Health.com featured the blog post below by Dr. Stephen Hochschuler, co-founder and orthopedic spine surgeon at Texas Back Institute.

Stephen_Hochschuler_MD

Facet Joint Pain after Spine Surgery

The facet joints are two small joints in the back of the spine, on the left and right sides, at each level. These joints work with the discs to provide support and motion to the spine.

There are several ways in which these joints can produce pain:

  • Nerves in the joints can be compressed and/or irritated by inflammatory agents
  • Facet joints can degenerate, become arthritic, and produce pain by forming osteophytes (bone spurs) which compress nerves passing into the legs.

As with many joints, degenerative changes can occur in the facets, which can become painful. Degeneration is likely to occur in the spine as a part of the aging process, regardless if surgery has been performed or not. However, some types of spine surgery may alter load or movement patterns of the spine, which in turn can affect the facet joints.

Causes of Post-operative Facet Joint Pain

Facet joints may be related to pain after spine surgery in several ways:

  • These joints may continue to degenerate after a surgical procedure to treat a herniated disc or compressed nerve roots at the same spinal level
  • Surgery may change the loading or movement patterns of these joints, leading to degeneration and pain.

Following a spine fusion at one spinal level, motion of the level(s) next to it may be altered to compensate for changes the fusion caused. This change in motion pattern may cause facets at the adjacent segment(s) to degenerate and become painful.

Facet joint pain is difficult to identify without injections into these joints. In back pain patients, pain may arise from more than one source within the spine. While surgery may address one problem, existing facet joint pain may not have been recognized prior to the spine surgery, and therefore not addressed.

Treatment Options for Facet Joint Pain

Treatment of facet joint pain may include one or a combination of the following:

  • Physical therapy
  • Medication
  • Chiropractic care/manual manipulation

If these treatments do not provide relief, then more invasive procedures are an option, including:

Treatment Considerations

The most important aspect of pre-operative planning for facet joint pain is the diagnosis. As with real estate investments, where the focus is on “Location, Location, Location,” for spine surgery the name of the game is “Diagnosis, Diagnosis, Diagnosis.”

It is therefore stressed that before any spinal surgical intervention is considered, a thorough diagnostic work up is needed to determine any and ALL causes of the back pain one is addressing.

This is part of the reason that a preoperative discussion and a patient education program is necessary. This process will afford the patient a full understanding as to what is known and unknown in each individual case and what expectations can be set in accordance with all treatment variables.

The EMG Study

As featured on Spine-Health.com. Dr. Patel is a physiatrist and treats patients suffering from neck and back pain.

Contributed by Nayan Patel, MD

For the spine patient with Failed Back Surgery Syndrome, the electrodiagnostic study helps the physician assess for nerve damage coming from the cervical or lumbar spine, as well as evaluate for other nerve-related problems in an extremity (such as peripheral neuropathy).

Because symptoms from a patient withFailed Back Surgery Syndrome can be complicated, additional electrodiagnostic tests can help the physician with accurate diagnosis of the origin(s) of the patient’s pain.

An electrodiagnostic study, commonly called an EMG, is used to evaluate muscle and nerve function of a person who has extremity or facial pain, numbness and/or weakness. The study can be used to assess for cervical or lumbar radiculopathy (nerve damage from spine disease), any co-existing peripheral neuropathy (nerve damage from diseases like diabetes), myopathy (muscle disease) or focal neuropathy.

The test also helps localize the location of spinal nerve damage as well as distinguish if the damage is new or old, and progressive or stable.

There are two parts to an electrodiagnostic evaluation: nerve conduction study (NCS) and electromyography (EMG).

Nerve Conduction Study (NCS)
The NCS is done with a stimulator that generates a mild shock that travels down the nerve; the signal generated is picked up by an electrode placed at a specific distance. The data obtained give the testing physician information regarding the speed and strength of the nerve signal. The NCS picks up signals from two types of nerves: the sensory nerve, which provides sensation signals from the skin, and the motor nerve, which provides power signals to the muscles.

Electromyography (EMG)
The EMG study is done with a sterile, small gauge amplifier needle inserted into the muscles of an affected extremity. Each muscle is powered by specific sets of spinal nerves: for example, the bicep is powered by the C5 and C6 spinal nerves. If an abnormality is seen in the activity of a muscle or group of muscles, the physician can determine which spinal nerve is likely involved. The study can also help assess the age, extent, and possible progression of damage.

The complete EMG test takes 30 minutes to one hour. Although uncomfortable for some patients, the test is well tolerated and there is no persistent discomfort. The ordering physician may use the study in conjunction with other diagnostic studies, such as an MRI or CT scan, especially if the problem is thought to originate in the spine.

Since a patient who has failed spine surgery syndrome can have complicated symptoms, the evaluating surgeon can have difficulty telling if a person’s ongoing pain is coming from a spinal nerve. The EMG study will help evaluate active versus inactive spinal nerve damage as well as localize the spinal level of nerve damage. It will also help assess for any coexisting peripheral nerve damage.

Failed Back Surgery Syndrome

The post below was featured on Spine-Health.com and was contributed by Dr. Stephen Hochschuler, co-founder and orthopedic spine surgeon at Texas Back Institute.

Failed Back Surgery Syndrome (FBSS) refers to chronic back or neck pain, with or without extremity pain, which occurs if spine surgery does not achieve the desired result. Contributing factors include recurrent disc herniation, compressed nerves, altered joint mobility, scar tissue, muscle deconditioning and degeneration of facet or sacroiliac joints.

The problem of failed spine surgery has long been a perplexing and intriguing problem my colleagues and I have tried to accurately analyze and pro-actively prevent. My goal as a spine surgeon is to help treat patients with pain stemming from their spine. Many times I am able to treat patients with nonsurgical treatment options, such as physical therapy or medication, and they do very well. In some instances though, this treatment plan does not provide patients with the pain relief needed so we have to pursue more aggressive treatment options including surgery.

I always consider surgery to be a last option approach to spine care and therefore am very careful to make sure my patients are in the best position to have a successful surgery, in turn minimizing the chances of FBSS. Through experience I know there are several factors that have shown to contribute to failed back surgery syndrome, and therefore I follow the protocol below to make sure my patients are set up for their best outcomes:

  1. Before the surgery:
    • Always treat patients conservatively (non-operatively) first
    • Make sure the patient is correctly diagnosed – meaning that the cause of the patient’s pain has been accurately identified
    • Provide a thorough pre-operative evaluation
    • Make sure the surgery is the right one for the patient
    • Appropriately educate and set expectations for the patient, including pre-operative psychological evaluations.
  2. During the surgery:
    • Take all proper precautions to minimize intra-operative issues.
  3. After the surgery:
    • Keep a close eye on post-operative recovery
    • Work closely with the patients’ interdisciplinary care team.

If you are considering spine surgery, it is important to sit down with your surgeon and determine how he actively attempts to minimize the risk for failed back surgery syndrome. If you have been diagnosed with FBSS, it is not necessarily the end of the road. There exist many alternative treatment approaches to deal with this syndrome, but once again one size does not fit all. It is important to find a surgeon who has experience in treating patients with FBSS and can offer you multiple treatment options.

Dr. Scott Blumenthal was the first Orthopedic Spine Surgeon in the US to perform an Artificial Disc Replacement (ADR) surgery. This life changing surgery has now helped over 1,400 Texas Back Institute patients. Recently SpineUniverse.com featured the blog post below about the choosing the right spine surgeon for you.

Choosing the Spine Surgeon Who Is Right for You

Patients often wonder how to choose a spine surgeon to perform their total disc replacement.

The easy answer to this question is simple:  carefully.

The longer answer to this question is:  do your research, both on your surgeon and on the procedure.

Tips for Choosing a Spine Surgeon for Disc Replacement
While thousands of surgeons have been trained in disc replacement techniques, very few have adopted it into their clinical practice with any regularity.

Certainly, the bare minimum requirements for choosing a surgeon would be to ensure he/she is a board certified or board eligible orthopedic or neurosurgical spine surgeon.  “Board certified” means that the doctor has gone through a rigorous testing and peer evaluation process by a specialized medical board.

You can ask your doctor if he/she is board certified, or you can research it online.

Some tips to get a better feel for the expertise of the surgeon are:

  • Ask how long he/she has been performing disc replacement surgery and with what frequency they do this procedure.
  • Make sure your surgeon performs many types of surgery and can tailor your treatment to be most appropriate for your condition. Not every patient is best served with a spinal fusion, nor is every patient best served with disc replacement.
  • Make sure you have open communication with your physician.
  • Make sure you trust and have confidence in your surgeon’s abilities.
  • Look at the surgeon’s academic credentials or published papers.  Find out what they have written on disc replacement and if they are leaders in this specialized area of spine care.

A warning to patients:  Don’t depend on fancy advertising or marketing when choosing a surgeon.  Use all your resources when making a decision this critical. The Internet, medical directories and societies, as well as your regular physician can all be great resources in helping you decide which surgeon to go to.

There are also additional resources such as patient chat rooms and blogs where you can read about other patients’ experiences with surgeons.

Choosing a spine surgeon is a very important decision, and the more facts you can get, the better. Luckily, there are many resources to help you find a spine surgeon who is right for you.

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