In Virginia, a less invasive approach to a widespread pain problem

By WP BrandStudio

August 6, 2019

Most people will experience back pain in their lives. So one hospital is developing cutting-edge treatments.

A few years ago, a yoga instructor showed up in the office of Joseph O’Brien, a spine surgeon at Virginia Hospital Center (VHC). The patient was struggling with pain, and was even unable to teach, because lower-back arthritis had caused a bone to slip out of place and pinch a nerve.

For many patients, such a situation might lead to major surgery and a months-long recovery process. But O’Brien used a treatment technique involving smaller incisions and less tissue disruption, which minimized damage and reduced the amount of pain. Thanks to this approach, Dr. O’Brien’s patient needed only a small dose of pain medication while in the hospital, and within weeks he had recovered enough to get back to his passion.

“It’s just one example of how we can take somebody who needed surgery…and [get] him back to his active lifestyle in a relatively short period of time,” O’Brien said.

About 80 percent of people will experience lower-back pain at some point in their lives.^[1] Discomfort caused by back pain, combined with the loss of work and restrictions on enjoyable activities, can be debilitating. It’s also a huge drain on the economy; lower-back and neck pain accounted for $87.6 billion in national health care spending in 2013, ranking behind only diabetes and heart disease.^[2]

As such, tackling back pain has become a priority for hospitals like VHC, where surgeons and other clinicians constantly research and develop new approaches that can address the underlying causes of this nationwide problem.

Exhausting all options

VHC’s physical and occupational therapists frequently see patients who are dealing with back pain from various causes, including injuries, surgery recovery and, most commonly, the simple wear and tear of daily life.

Many Americans have lifestyles that require a lot of sitting, which can lead to back problems, said Ron Donelson, an orthopedic surgeon in New Hampshire. He used the analogy of a jelly doughnut being squished on one side to explain what happens to a spinal disc in this position: When we bend our spine forward at a desk, on the couch or in our cars, the “doughnut” compresses on one side while staying the same height on the other. This puts pressure on our nerves and leads to pain, according to Donelson.

Regardless of whether the pain is from daily strain, surgery or an injury, patients at VHC are first seen one-on-one by a physical therapist and undergo an evaluation that includes a thorough history and physical exam. The main focus of this process is to explore different therapy techniques that reduce pain and avoid narcotic use, since medication dependence often begins during recovery from an injury or surgery, said Justin Trumbull, a physical therapist and orthopedic clinical specialist at VHC.

Sometimes, despite all other interventions, surgery is necessary. And while the vast majority of back surgeries performed in the United States are still invasive, involving the moving of muscle and tissue that lead to postoperative pain, VHC’s team primarily performs laparoscopic surgery.

But this kind of surgery isn’t right for everyone. According to VHC neurosurgeon Richard Murray, the best candidates are patients with a single, specific problem that can be addressed by operating in one small spot.

“If you can minimize the amount of soft tissue damage that you have as a result of [surgery], then people do better,” Murray said. “What we’re talking about is the difference between a patient spending a number of days in the hospital versus a patient being discharged on the first day after the operation.”

Reducing the need for narcotics

VHC focuses on minimizing pain and opioid use before, during and after surgery, for the reasons described by Trumbull. One of their most unique and innovative strategies is the use of the enhanced recovery after surgery (ERAS) protocol for spine patients, which aims to reduce pain and narcotic use. When implemented, the team at VHC saw patients use about a third of the amount of narcotics as those who have had traditional surgery and anesthesia.

The overarching goal of the ERAS protocol, according to anesthesiologist Thuy Anh Ashley Nguyen, is to minimize the stress response to surgery, since it impairs the body’s natural healing process. At VHC, the protocol involves pre-medicating with non-narcotic medications and having the patient drink a carbohydrate drink to decrease fasting time before surgery and optimize their metabolism for healing afterward. After surgery, patients receive a three-day numbing medicine instead of the traditional analgesic, which can have significant effects on the nervous system and undesirable side effects.

“I’ve had a handful of patients now that had minimally invasive spine fusion and took no narcotics while in the hospital postoperatively, which is somewhat unusual,” said O’Brien.

This experience is born out in at least one recent piece of research. A study published in the Journal of Neurosurgery: Spine showed that a similar ERAS protocol led to less need for opioids while in the hospital; after one month, only 38 percent of ERAS patients were using opioids, compared to 53 percent of those who’d had traditional surgical care.^[3]

Leading an industry-wide change

Opioids aren’t the first line of defense for back pain, but they are sometimes prescribed for it, as well as for acute pain from an injury or surgery. On top of the addictive nature of these medications, they can also cause a litany of physical issues in those who take them, including problems with digestion, respiration, mobility and clotting, according to Murray.

Research also shows that nerves can become hyper-reactive to even normal stimuli when a person takes opioids for an extended period of time, making them tolerant to the drugs and unable to control their pain—a phenomenon known as opioid-induced hyperalgesia.

VHC’s clinicians may not be able to prevent back pain, but they are hopeful that the tide is turning when it comes to treatment and recovery.

As O’Brien explained, there’s a steep learning curve when it comes to mastering more minimally invasive methods, especially for complex surgeries. But as the connection between back surgery and opioid dependence becomes clearer, and the research showing the benefits of less invasive methods becomes stronger, hospitals across the nation are devoting more time and money to these new techniques.

“I think as time goes on, we’re going to see the pendulum swing,” said O’Brien. “It is my hope that more of the community will be pursuing these minimally invasive methods.”

Learn more about spine and back pain services at Virginia Hospital Center.

________________________