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.

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.

Day 10 – Ebola?

Today we only had one case booked at Mulago hospital. We all woke up in the morning a little bit unsettled because we had all heard conflicting stories as to what the state of Mulago was in regard to the Ebola situation. Although most of the stories involved New Mulago, which is a part of the greater Mulago hospital, but located a short distance away, we were still not completely clear what was true and what was hearsay  As it stood, only half of the team was meant to go to Mulago to work on the case. There definitely seemed to be some tension within the team because it seemed like people were unhappy about this situation, but no one was speaking up. Thankfully, before we headed out, there was a team meeting called where we were told what was shared with Dr. Lieberman from the acting director of Mulago Hospital, and from his perspective it was safe for us to go in and perform the operation.

Off we went in the van, the group of us scheduled to do the case at Mulago. This case was an idiopathic scoliosis instrumentation, reduction and fusion on a 21-year-old female. Despite being slightly nervous about the Ebola situation, we all pulled together as a team and supported each other, mostly with lighthearted humor about the situation, and got through the case very successfully.

Day 11 – Last Day of Surgery at Mulago

Today there were two cases planned, one at each of the hospitals. At Case Hospital, we had planned to perform a difficult procedure on a 3-year-old female with a mass in the cervical region of her spinal cord. Knowing the delicate nature of this procedure, Dr. Holman had organized late last week to have some of his more specialized neurosurgery equipment shipped from the United States to help perform this procedure. Unfortunately, although it appeared that the shipment had arrived in Uganda, it was being held up by customs, and thus we were unable to obtain it. Consequently, this case had to be cancelled. This was such a frustrating outcome, after having planned to perform this procedure, and hopefully make a real difference for this little’s girl life, but instead the Ugandan government prevented this from happening.

While the Case half of the team were dealing with their setbacks, the other half of the team was working on a case at Mulago on a 50-year-old female with a suspected infection in her spine. This group at Mulago also faced their own set of obstacles in trying to undertake this case. When we arrived in the morning we found that the instruments we needed for the procedure had not yet been sterilized, and furthermore, the truck that was supposed to come and pick it all up to take it to where it can be sterilized, was out of gas. As we waited around for the necessary equipment, we rounded on patients, caught up on writing operative reports, grabbed a quick power nap, and Dr. Ughwanogho cracked the whip to ensure our patients were getting their post-operative x-rays after being told that they couldn’t get them because they had to pay for them themselves. Dr. Ughwanogho’s persistence paid off and sure enough, before we knew it we had all of the post-operative x-rays.

Finally, at around 1 pm, we had our instruments sterilized and returned, the patient was ready, and we began the case under the very competent leadership of Dr. Ughwanogho, with assistance from two Ugandan orthopedic residents. There was some uncertainty going into this case because this particular patient had been investigated for an infected process in her spine, but we did not know exactly what we would find. What we did find was a very inflamed spine, with cavitating lesions. Due to the precarious state of this patient’s bones, likely due to underlying  osteoporosis, this case took longer than we had anticipated; plus, we had had a considerable late start. Bottom line, it was a late night at Mulago, and when we finally had finished it was around 8 pm.

The rest of the team had gone to an evening reception, hosted by the Mulago administration, but as we had had a long and frustrating day, exhausted and starving, we headed home and went out to grab a late dinner. We eventually met up with the rest of the team at the apartments and discussed the trials and tribulations of the day, but encouraged by the positive outcome for the patient. Moreover, I think this was an important day for Dr. Ughwanogho, as he was able to reaffirm to himself just how talented and competent he is as a young orthopedic surgeon, even in the most adverse conditions.

Day 12 – Last Day in Uganda

Today, our last day in Uganda, was spent operating on a 5-year-old male with congenital scoliosis at Case Hospital. While half of the team was at Case operating, the other half of the team went to Mulago to wrap up any loose ends, check in on post-operative patients, and clean up our equipment. Once we had finished up at Mulago, we bid a bittersweet farewell to this place that had quickly become a home away from home for several of us. Although we had only been there for two weeks it became very apparent to us that we had established very strong and special relationships with the health care staff we had been working alongside; not to mention the relationships we had formed with the patients we had operated on and were now on their way to recovery. To me there was definitely a sentiment of this trip not being long enough. It seemed like just when we were starting to get into the swing of things, and starting to really mesh with the Mulago staff, it was time to go. Afterall, there is always more we could do.

Once we had finished up at Mulago, those of us who were not part of the operating team at Case went home to work on outstanding reports, sorting of the thousands of pictures that will be necessary to supplement the trip report, and catching up on other odds and ends. However, our ability to do work was interrupted by a building-wide power outage. Thankfully a generator was brought in, but only lasted as long as a full tank of gas, and then we were once again powerless. This made for more of relaxing afternoon that we had anticipated, but we were not too upset about that!

The operating team finished up the case successfully and without any complications. Upon their arrival home, we all packed up, sorted out the equipment that would be getting shipped back to the United States, and cleaned up the apartments, as we had an early morning departure on Friday morning. After all of our dirty work was completed, we gathered for our final team dinner at a restaurant called The Lawn. It was a lovely evening, with great food, drink, company and lasting stories and memories shared among us all. As usual we shared our personal lessons, but this time it was the lesson of the trip. Although we all shared very profound and meaningful lessons, it became obvious to me that this trip could never be summed up in a single lesson. Each of us has learned invaluable lessons from our patients, colleagues, from the Ugandan way of life as a whole; and more importantly learned more about ourselves than we probably even know. It is my hope that these lessons and memories remain strong and fresh in my mind for years to come.

Uganda Mission

November 6, 2012

Day 9 – Second Week Begins

Contributed by Erin Sadler

                Today marked the beginning of the second week of surgery. We had procedures taking place at both Mulago and Case Hospitals. At Case Hospital, Dr. Lieberman was performing a revision of hardware. At Mulago, Dr. Ughwanogho, one of Dr. Lieberman’s fellows, completed his first case on his own. He did a fantastic job operating on a 20 year old male with a cervical burst fracture. It was not only his surgical competency that I was so impressed by, but earlier in the day while he was rounding, Dr. Ughwanogho blew me away. It was during his interaction with a young man who had been in a motorcycle accident and had an odontoid fracture in his neck. After discussing with him the potential surgery that may be necessary for him, Dr. Ughwanogho proceeded to get to know more about the patient, and in doing so learned that he was in school training to be a pilot. Furthermore, learning the operation he had been suggesting, could potentially compromise this young man’s future career. Immediately, Dr. Ughwanogho realized these implications and quickly adapted his plan to accommodate an outcome that is more in favor of this young man’s future profession. Dr. Ughwanogho’s display of compassion and patient-focused care makes him a very strong role model that any surgeon-hopeful can, and should, look up to.

                After a long day, we arrived back home and turned on the television to watch some Olympics, but were quickly distracted by the CNN headlines of the Ebola outbreak in Uganda. After a few seconds of watching we were even more surprised to see a screen shot of the Mulago hospital, the hospital we had just operated at all last week, and all day today. Although we had been aware that Ebola was present in the Kibaale district, we were not informed of its presence at Mulago until now. This made most of us quite uneasy, and in no time family members were sending emails and texts sharing their concerns for our safety. We were later told that Mulago had not yet confirmed cases of Ebola, but there were several health care professionals being quarantined. We were more reassured when we heard that the airports were still open, there had been no travel restrictions placed on Uganda, and the belief from health officials that if there was any suspicious virus, it had been contained at Mulago.

                In an attempt to take our minds off of our worry about the current situation, we went for an absolutely incredible dinner at the Kampala Serena Hotel. This buffet dinner had the most delicious fresh avocado  smoked tilapia, beef kebabs, and a smorgasbord of desserts. After filling ourselves to the brim, we headed home. Before going to bed, much to the delight of our Polish anesthesiologists, we watched the Poland Men’s Beach Volleyball team (or as Jason astutely puts it, “sand” volleyball since they are not playing on a beach during this Olympics) defeat the USA team.  We then retired to bed, some us quite nervous as to what tomorrow would hold with respect to going to Mulago to operate, and furthermore, the implications of our travelling home with this health threat brewing.

Uganda Mission Day 8

November 5, 2012

Uganda Mission

We finally have the final blog posts from Dr. Lieberman’s Uganda trip!

Day 8 – Seeing More of Kampala

Contributed by Erin Sadler

The day started with some of the team heading off to round on post-operative patients at the respective hospitals. The others who remained at the apartments spent the morning doing laundry, finishing up some work, catching up on other odds and ends, plugged into the Olympics, and in Dr. Holman’s case: fighting a suspected case of food poisoning. In the early hours of the morning, it came to Ngozi’s and my attention that Dr. Holman was feeling under the weather. By the time the morning arrived he was feeling worse and we were all concerned that he had eaten something bad that was taking a toll on his system. It was no surprise that Liz took on the nurturing role of nurse to keep a close eye on him.

Once everyone had returned from rounding, we decided to spend the afternoon going to the art market and gain a more inside look at Kampala by visiting the city market. We had initially thought we would visit the Bujagali Falls, but the previous day, during our return from Putti, we had sat in traffic for over an hour, and thus we were hesitant to take this same route, and spend the afternoon baking in a vehicle stuck in bumper to bumper traffic. Instead, we settled on the local markets. After getting a grocery list from Liz with remedies for Dr. Holman, including salted crackers, ginger ale, and Lucozade, we headed off in the bus to exercise our bargaining skills at the market.

The art market is an area in the center of town where various vendors have set up booths and sell their goods. There is everything from jewelry to art, to authentic Ugandan clothing, pottery, and other trinkets. Going from booth to booth we began to appreciate not only the art of the vendors, but the art of bargaining the price down. This was best demonstrated when we were looking at the section of the market with paintings. It was quite entertaining to see Brian attempt to exercise his negotiating prowess to try and get a painting from 150000 shillings to 80000. Although he claims he “won” since he did not end up paying more than he wanted, he also walked away empty-handed because the artist wouldn’t budge below 90000. Others were more successful, and came away with treasures that they had negotiated to a reasonable price.

From the art market, we courageously ventured to the real Kampala city market where goods are bought, sold, and traded. This was an absolutely incredible experience, to gain an insider’s look at the local commerce of Uganda. We also gained important knowledge regarding appropriate attire to wear in Ugandan public: women should not wear shorts. Unbeknownst to me, wearing shorts is the closest thing to being naked, as in Ugandan culture, a women’s thighs should only be exposed to her husband. I guess I had to learn this lesson the hard way, as many of the locals were taking pictures and quite interested in the “Muzungu” who was “naked.” Needless to say, the group of us was quite a spectacle to see wandering through the maze of alley-ways filled with mountains of clothing, shoes, electronics, and various food products and other provisions. This visit did serve a greater purpose; upon seeing the glorious local produce, we were inspired to buy ingredients to make guacamole. Under the keen eye of Chef Brian, we selected and bought the finest avocados, garlic, onions, hot peppers and limes. After making our way safely back to the vans, with our purchases in tow, and the new knowledge of what not to wear, we headed home. After a quick stop at the Nakumatt (the 24 hour grocery store) to buy a few more key ingredients including cilantro, salt and chips, we arrived home, all of us anticipating Brian’s creation. I have to admit I was skeptical, but Brian proved to be quite the chef, and concocted some of the most delicious guacamole I have ever tasted.

After our delicious appetizer, we decided to have our second dinner at Khyper Pass, the delicious Indian restaurant we had gone to on the first evening. Unfortunately, Dr. Holman was still feeling sick, and after giving him a few litres of intravenous saline and reminding him what it is like to be on the patient side of health care, he was still not up for taking solid food, so we headed off without him, promising white rice upon our return.

With our bellies full and white rice for Dr. Holman, we returned home to play a lively game of “Things.” Hopefully you have played this game, because in my opinion it might be the most fun game ever created. Needless to say, the rest of the evening was filled with hysterical laughter, learning a lot about each other, perhaps even things we may not have wanted to know, and most importantly, the complexities of Brian’s relationship with his cat, Max.

Spine Health Day

October 16, 2012

Happy Spine Health Day!

October 16th is Spine Health Day and in honor of such an important day here at Texas Back Institute here are 5 tips for maintaining a healthy spine (in no particular order) from Dr. Rey Bosita.

1. Maintain a healthy body weight.

Being overweight, especially belly fat, can put additional stress on your muscles, ligaments and tendons in your lower back.

2. Quit smoking.

Smoking can increase the risk of many life threatening illnesses. Smoking can impair blood flow to many parts of the body including the back which in turn slows down the healing process.

3. Work on your core. 

Core muscles help support the low back and pelvis.  Strengthening these muscles will help increase your spinal stability as well as reduce your risk of injury.

4. Get enough sleep. 

Sleep is essential to your overall health but it also plays an important role in maintaining a healthy spine.

5. Pay attention to any warning signs.

 It is important to listen to your body. It can be common to experience back pain once in a while, however, sometimes it can be an indication of a more serious problem. Consult with your physician to determine what is causing your pain. The best time to act is before a problem starts when there is no pain.

What are some of the things you do to maintain a healthy spine?

Artificial Disc Replacement

Texas Back Institute is a global leader and pioneer in spine care, having performed more than 1,400 artificial disc replacement procedures with 14 different types of ADR devices, beginning in 2000 with the first ever performed in the United States. One of the latest advancements in spine surgery, artificial disc replacement gives our patients an opportunity to retain mobility and resume their lives with minimal pain or discomfort. Led by the world-renowned spine surgeons at our Center for Disc Replacement, we perform this motion-preserving, life-changing procedure on patients from around the globe each year. If you’re suffering from chronic back or neck pain, our concierge services team will help you coordinate all aspects of your visit to TBI so you can receive treatment from some of the best spine surgeons in the world. It’s your time to get back to life.

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