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Putting back care at the forefront - 01/10/2008

Construction worker Robert O’Donnell counts on two things to get his job done. The first is good weather. The second is a good back. “My back would go out a couple of times a year,” recalls O’Donnell, 54, of Bristol. “Knock on wood. It hasn’t happened within a year.”

In 1998, his pain peaked with two herniated discs. “I had the sciatic nerve going and it felt like a knife sticking in my back. The pain was constant.” O’Donnell’s experience is classic, according to Letterio Asciuto, M.D., his primary care physician. When a disc herniates, its gel-like center extends beyond disc ridges. “It can develop slowly or come from a sudden event, like a sneeze, twisting or bending over to lift a heavy object,” says Asciuto. “Typically, it’s someone taking their groceries out of the trunk — that’s also very common.”

Fortunately, for O’Donnell, recovery has come pretty quickly. Besides regular exercise, the avid bike rider, skier and rollerblader also relies on anti-inflammatory medication and
chiropractic care for treatment. “The stronger I stay, the better I am,” he quips. “I haven’t had surgery yet.”

“Most patients, if given appropriate time to heal, do not need surgery,”says Asciuto, on staff at The Hospital of Central Connecticut (HCC). For conditions that might not rebound from conservative treatment, the hospital offers advanced techniques in spinal surgery and pain management. Recently, it was the first hospital in Greater Hartford, and only the second in the state, to implant an artificial cervical spinal disc. The hospital also conducts lumbar disc replacement, another state-of-the-art procedure.

Managing back pain
Sometimes it’s the everyday activities — lifting toddlers, raking leaves, or manual labor — that can twist or sprain the back. But for most everyone, just getting older brings on ailments. “Our spines wear out over time, and the vast majority of back pain is caused by the natural aging process,” says HCC neurosurgeon Edward Akeyson, M.D., Ph.D. Back pain typically affects eight out of 10 people at some point in their lives. Low back or lumbar pain is most common, and is the leading cause of job-related disability, according to the National Institute of Neurological Disorders and Stroke. “The spine holds the body up. It makes it move. It offers very complicated movement and it encloses the nerves,” says Joseph Aferzon, M.D., chief of Neurosurgery. “It can also fail as a structure, can fail in movement, and can pinch on the enclosed nerves.”

The back supports 33 vertebrae split among the lower, center (thoracic), and neck (cervical) sections, and discs that separate vertebrae. It also houses facet joints, nerves, muscles, ligaments, and the spinal cord. O’Donnell’s herniated discs, confirmed through a CT scan, exemplify what Aferzon terms a structural problem, in that it affected the back’s normal function. Another example is disc degeneration. Mostly in the lower back, it’s caused by a soft tissue breakdown, and can trigger arthritis. Both disc conditions can cause a pinched nerve and bring on sciatica, that numbness or pain that radiates to the buttocks, through the leg and into the foot.

Musculoskeletal injuries like sprains or breaks is another category of back ailments, affecting its muscles, bones and ligaments. Damage or wear to one part of the back can cascade into an agonizing, and at times debilitating, condition. When back pain continues for more than three months, even after conservative treatment, it’s called “chronic pain.” “Pain is a chronic disease. There is no cure. It’s a treatable condition with its ups and downs,” says HCC interventional pain management specialist Eric Grahling, M.D.

As a physician in practice for more than 30 years, Ellen Donshik, M.D., had a pretty good idea of what was causing acute soreness to her back that started about three years ago. An HCC radiologist who could also interpret her own findings, she knew and felt what results showed. “I have a lot of terrible back pain,” says Donshik, who suffers from scoliosis, facet joint arthritis, osteoporosis, and several collapsed vertebrae that contribute to a narrowed spine (stenosis). “It just got so bad I couldn’t walk on the treadmill anymore,” she says. Donshik found short-term relief with interspersed steroid injections. Several months ago, a colleague mentioned pain management advances at The Hospital of Central Connecticut. In October, Grahling performed medial branch radiofrequency therapy to Donshik’s lumbar facet joints. This therapy uses heat to destroy the nerves contributing to pain that originates in the facet joints. The procedure can provide relief for up to two years. “It was the first time in years that I was able to walk without
terrible pain,” says Donshik, shortly after the procedure. Grahling says pain management treatment often enables patients to pursue physical therapy to strengthen the back and abdominal muscles. A lot of chronic low back pain stems from arthritis, he says, with inflammation targeting bones, ligaments and tendons.

Other common causes of chronic low back pain include
muscle spasm, spinal stenosis, bulging discs, and nerve pain. Outpatient pain management treatments for the low back include:
- Trigger point injection – A local anesthetic, with or without steroid, is used for severe muscle spasms or chronic headaches.
- Epidural steroid injection – Treats acute conditions in herniated discs or stenosis.
- Nerve block – An anesthetic and usually a steroid are injected around a nerve.
- Facet injection – This uses an anesthetic and sometimes steroid.
- Discectomy – A needle is used to remove a tiny amount of a degenerative or herniated disc.
- Intradiscal electrothermal therapy – Heat is applied through a needle, providing temporary relief at the disc.
- Spinal cord stimulation – For post-surgical patients with sciatica, electrodes are placed permanently in the back to replace the shooting pain with a tingling sensation.
- Vertebroplasty – Small compression fractures, often caused by osteoporosis, are cemented together. This procedure is also done by Hospital of Central Connecticut interventional radiologists.

Newer surgical techniques offer relief
Advances in surgical care at The Hospital of Central Connecticut are bringing new hope to patients whose livelihoods are greatly diminished by problem discs. After an MRI revealed a bulging cervical disc, bone spur and degenerative arthritis, Cindy Bossi, 54, welcomed the idea of getting an artificial cervical spinal disc implant. This past September, she was the first patient in Greater Hartford and the second in the state to undergo the procedure, conducted by HCC neurosurgeon Ahmed Khan, M.D. Weeks before her surgery, Bossi suffered from a stiff neck, and shoulder pain that extended into her arm, associated with tingling hands and fingers. “I would be writing, and the pen would just fall out of my hand,” the Southington resident says. Pressure on the nerve roots and spinal cord from the herniated disc caused Bossi’s symptoms. For her, disc replacement was the preferred alternative to spinal fusion. Fusion removes the disc and replaces it with a bone graft and uses screws to attach two or more vertebrae together .“Fusion can be very effective, yet it can limit range of motion and flexibility in the neck. It can also add pressure to adjoining discs, causing them to degenerate more quickly,” says Khan. Insurance coverage, however, is a potential obstacle to some patients who are implant candidates, note Akeyson and Khan.

Bossi’s PRESTIGE® Disc functions like a normal joint, allowing patients to bring their chins to their chests, look up, bend their necks to either side and turn their heads. Just two weeks after surgery,Bossi was back at work, having achieved full recovery within about six weeks. She’s back to knitting and crocheting .“I’d recommend the surgery to anybody,” she says.