As a 4th year intern at Yo San University Clinic, I am always thirsty for more integrative study of pain management. During my one-year internship, low back pain, hip pain, sciatica pain and leg pain are the most common ailments I have seen in the clinic. I realized that pain in these areas is related to spinal issue in many cases. Thankfully, most of my patients’ conditions responded well to acupuncture treatment at the Hua Tou JiaJi, UB points and Local Ashi points. However, I also experienced there was no improvement for a few patients after treatments. Whenever I saw these patients suffering from the same pain without any improvement after a few treatments I felt very guilty and heavy with worries without clear clues. Therefore, I was seeking an intensive and live western medical learning opportunity to see more pathologic spinal conditions of patient who have already been through spinal surgery or considering surgery to control the pain. I believe that with better understanding of various pathological spinal conditions and treatment methods in the western medicine including spinal surgery processes, I can provide detailed explanations about how acupuncture and herb help their condition in an integrative way with their western treatment or surgery.”
I want to share my excellent observation experience at the Department of Spinal Surgery of the St. Jude Medical Center in Fullerton on August 24,2015. It was before sunrise but I was so excited to drive down to Fullerton to observe spinal surgery. Unsurprisingly, I was so nervous at the beginning but I felt more excited later. I was so appreciative to be chosen and welcomed by the staff and medical team at St. Jude Medical Center. Under the guidance of our Dean of Clinical Education, Dr. Lee, I shadowed Dr. Ali (Raed Ali MD) who has more than 15 years experience of spinal surgery.
Before surgery began, Dr. Ali explained briefly the lumbosacral spine MRI of his patient and surgical process he would perform for 6 – 8 hours. The patient was a mid-fifty male with severe chronic low back pain radiating to hip and legs due to the degenerative disc condition, degenerative bulging disc, spondylolytic spondylolisthesis causing pain for daily activity. Prior to the spinal surgery, Dr. Ali advised that pain would not be fully alleviated but the patient would feel better with 50-60% reduction of pain after surgery. I appreciated his honesty but I was a little bit disappointed with the low expectations in reality. However, even though this surgery could not take his pain away completely, reduced pain might encourage the patient to exercise more frequently which could eventually improve not only his spinal condition but also his obesity. During my conversation with Dr. Lee, I was fascinated about how acupuncture can work with western treatment in the real world. With more than an 8 year friendship, Dr. Ali and Dr. Lee have been cooperating in the integrative way by discussing patients’ conditions and better treatment methods between the acupuncture treatment and the surgical procedure depending on the severity of the each patient’s condition. I was fascinatedto see Dr. Ali’s great respect for the acupuncture treatment as a natural non-surgical healing process for the pain. He said that he prefers to have his patients try acupuncture treatment first to avoid major surgery.
This was complex major surgery for Bone graft spinal fusion to treat degenerative bulging disc at L2 & L3 and Laminectomy at L2, L3, L5 & S1 & S2 (regions). The procedures started with LLIF Surgery (Lateral Interbody Fusion) at L2 and L3 on Lateral position for about 3 hours and followed by Laminectomy at L2, L3, L5 &S1 &S2 (regions) at posterior position for hours. The procedure was performed through the patient’s side, avoiding the major muscles of the back for minimal tissue damage, minimal blood loss, small incisions and scars, minimal post-operative discomfort, so thepatient was expected to return to normal function with quick recovery relatively. (The LLIF is a type of interbody fusion, which is a category of fusion in which the disc in the front of the spine is removed and replaced with an implant containing a bone graft to set up the condition for the two vertebrae to fuse together through the disc space).
After the patient was in general anesthesia, a urinary catheter (a thin flexible rubber tube) was placed into the bladder through the urethra, the small opening through the tube which patient’s urine flows. Urine was draining out of patient’s body through the tube and into a plastic pouch, it prevents difficulties in the bathroom and is used for a few days after surgery.
First, the patient was positioned lying on his side. Then Dr. Ali used X-rays to locate the disc L2 and L3 that would be removed. After the disc was located, he marked the skin with a marker directly above the disc. Then he made a small incision (cut) in the flank and used his finger to push away the peritoneum (sac covering the abdominal organs) from the abdominal wall. He made a second incision directly on the side of the patient. Then a tube-like instrument known as a dilator was inserted into this incision. During surgery, several X-rays by encompasses the actual X-ray source and image intensifier (C-Arm) were taken to make sure that this dilator was in a good position above the disc. Then he inserted a probe (blunt tool) through a muscle to have real-time information about the position of the nerves relative to his instruments. Once the muscles were split apart, a retractor tool was put into place to direct access to the spine. After this direct access to the spine was achieved, He performed a standard discectomy (removing the intervertebral disc) with tools designed to cut and remove the disc. After the disc material was removed, the implant was inserted through the same incision from the side. This spacer (cage) was used to help holding the vertebrae in the proper position to make sure the disc height was correct and to make sure the spine was properly aligned. This spacer together with the bone graft, was set up in an optimal environment to allow the spine to fuse at that particular segment. X-rays showed the spacer was in the right position. For additional support to hold the vertebrae in place, additional implants, such as screws and rods were used.
In a spinal fusion, a solid bridge is formed between two vertebral segments in the spine to stop the movement in that section of the spine. Bone graft and/or bone graft substitute is needed to create the environment for the solid bridge to form. The bone graft does not form a fusion at the time of the surgery. Instead, the bone graft provides the foundation and environment to allow the body to grow new bone and fuse a section of the spine together into one long bone.
After LLIF, the patient was moved to the prone position for Lumbar Laminectomy. Laminectomy was performed at the L2,L3, L5,S1 and S2 to treat spondylolytic spondylolisthesis. Bone spurs and damaged disks were removed to take pressure off the patient’s spinal nerve and column because making more space between spinal nerve area means not only reducing pain but also providing better healing space for the nerve root. Incision (cut) in the middle of the lower back was made and then the skin, muscles, and ligaments were removed to the side by using a surgical microscope. Part or all of the lamina bones, small disk fragments, bone spurs and other soft tissue were also moved on both sides of the spine, along with the spinous process. Spinal fusion was processed to stabilize spinal column after surgery. At the end, The muscles and other tissues were put back in place. The skin was sewn together.
During my observation, I was wondering when the patient could move after surgery because I thought patients who have had or are contemplating lumbar fusion surgery are understandably concerned about making sure the fusion heals as intended. For this reason, I assumed that many patients must be afraid to be active and some do not want to move at all, fearing that they will risk having the fusion not set up properly. However, surprisingly, Dr Ali mentioned that his patient can start physical therapy the next day after surgery. The patient was encouraged to move on the first day after surgery. I found out more explanation about the reason along with recovery tips. According to spinehealth.com, “The patient is recommend walking frequently throughout the initial recovery period, increasing the amount and length of the walks as tolerated to the point of minor aching, but stop if there is any sharp pain. In actuality, and contrary to this fear, movement is very important to foster healing. There are precautions to keep in mind – most patients avoid bending, lifting, and twisting – but staying active with short, frequent, gentle exercise is strongly recommended and delivers many benefits because Movement activates supporting muscles. Following surgery or an episode of injury, smaller muscles in the area may become inhibited (turned off). These muscles have a great responsibility in maintaining stability of the spine. Encouraging the muscles to function properly will also reduce stress through the surgical site by active stabilization. Also Gentle stretching promotes flexibility. During periods of inactivity, range of motion can be lost, and stiffness soon settles in. Very gentle stretching of the core back and abdominal muscles, as well as the hip muscles attached to the spine and pelvis, will make all movement easier, even just getting out of a chair. Care must be taken to not be too aggressive too early, or a set back could undercut the benefit intended because Activity encourages healing blood flow. Blood brings the oxygen required to the healing site. Lack of oxygen will delay or sometimes prevent healing of tissues and healthy bone growth, which are critical to a successful fusion outcome.” On my way home after the observation, I wanted to write the article about my observation experience of the spinal surgery to introduce this excellent learning opportunity for interns who may be interested in pain management. I appreciate the Dean of Clinical Education, Dr. Lee, devoting his effort and friendship with Dr. Ali to bring new integrative learning experiences-externship rotation opportunities to Yo San. Also I appreciate Yo San’s support to create exceptional learning chances. This is one of the best learning experience for me. Thanks to Dr. Lee’s detailed explanations during surgery, I was able to solve my questions right away. For Yo San interns, I strongly believe that this integrative observation opportunity is a precious experience to understand intensive knowledge of spinal surgery in order to communicate with not only medical doctors but also patients seeking acupuncture treatment for pain management. After this observation, I found myself having more interests and better understanding articles related to spinal issues and treatments in western medicine. Therefore, I am certain that with further continued integrative study, I will provide patients more effective acupuncture treatment to support the spinal condition associated with/without post surgery to reduce swelling, inflammation, pain or weakness, numbness.