Frequently Asked Questions

Please click on the question to see the answer:

• WHAT CAUSES MOST LOWER BACK PAIN?
• CAN THE PATIENT DO ANYTHING TO PREVENT LOWER BACK PAIN AND SCIATICA PAIN?
• DO ALL PATIENTS NEED SURGERY ONCE THEY HAVE LOWER BACK PAIN AND SCIATICA AND THEIR TESTS ARE POSITIVE?
• WHAT IS MEANT BY A "PINCHED NERVE?"
• WHAT HAPPENS IF THESE ALTERNATIVE TREATMENTS DO NOT HELP?
• WHY WOULD I WANT TO CHOOSE SELECTIVE ENDOSCOPIC DISCECTOMY (SED)™ INSTEAD OF THE OTHER PROCEDURES?
• MY MRI SCAN SHOWS AN ABNORMAL DISC AM I READY TO HAVE THIS BACK SURGERY?
• I UNDERSTAND THAT THIS PROCEDURE IS DONE WITH LOCAL ANESTHESIA-HOW MUCH PAIN IS ASSOCIATED WITH THE DISCOGRAM AND THE SELECTIVE ENDOSCOPIC DISCECTOMY™?
• CAN I BE PUT TO SLEEP FOR THE DISCOGRAM AND BACK SRURGERY PROCEDURE?
• COULD YOU SUMMARIZE THE ADVANTAGES OF SELECTIVE ENDOSCOPIC SURGERY™ OVER OPEN BACK SURGERY?
• IN WHAT CONDITIONS WILL SELECTIVE ENDOSCOPIC SURGERY™ NOT BE RECOMMENDED?
• IF MY SELECTIVE ENDOSCOPIC SURGERY™ IS SUCCESSFUL WILL MY BACK BE COMPLETELY NORMAL LIKE IT WAS WHEN I WAS 15 YEARS OLD? WILL I BE ABLE TO BEND AND LIFT ANY HEAVY THINGS THAT I WOULD LIKE WITHOUT HAVING ANY PAIN?
• ARE THERE ANY COMPLICATIONS THAT OCCUR WITH SELECTIVE ENDOSCOPIC DISCECTOMY™ SURGERY?
• COULD YOU SUMMARIZE WHY SELECTIVE ENDOSCOPIC DISCECTOMY™ BACK SURGERY WORKS?
• IS THE DISC ENDOSCOPE JUST LIKE THE ARTHROSCOPE USED IN MY KNEE SURGERY?
• DO YOU REPLACE THE DISC WITH ANY OTHER MATERIAL?
• IS CHYMOPAPAIN STILL AVAILABLE?
• I AM 62 YEARS OLD, AM I TOO OLD FOR THIS BACK SURGERY PROCEDURE?
• I HAVE HAD X-RAYS DO I ALSO NEED AN MRI SCAN?

WHAT CAUSES MOST LOWER BACK PAIN?

There many causes of lower back pain. The lower back called the lumbar spine is made up of 5 vertebrae with their ligamentous attachments and small facet joints. The vertebrea surrounded by muscles and nerves and are separated by shock absorbers called lumbar discs. The most frequent cause of lower back pain is micro trauma to the muscles and ligaments. This type of injury almost always heals itself within about 6 weeks. More significant injuries to the lumbar disc can involved tearing of the covering of the disc called the annulus. The lower back pain associated with this injury is very severe.

CAN THE PATIENT DO ANYTHING TO PREVENT LOWER BACK PAIN AND SCIATICA PAIN?

To start out with having excellent posture is very helpful especially when sitting. Using a good supportive chair at work is very helpful. Of course, whenever you do any bending and lifting even of small items it is very helpful to maintain your lower back in a good position and bend with your legs. Stretching is very important on a daily basis to prevent minor injuries that occur with certain twisting movements. Stretching is important to maintain the flexibility and decrease the tightness in your paravertebral muscles which help maintain your spine erect. The psoas muscles are deep in your abdomen in the front of your spine and also can become tight and need good stretching. You're abdominal musculature help support your lower back. Maintaining good abdominal and lower back muscles by exercising regularly is also important. Your diet is also very important and of course, you should eat a balanced diet that has the necessary vitamins and minerals such as vitamin C, E and B complex. Minerals such as magnesium and calcium are important as well. The less weight that you carry puts less pressure on your lower back and helps preserve the integrity of your disks and joints. Avoiding repetitive impact activities such as running may lessen the strain on the lower back as well thereby lowering the chance of you developing lower back pain and sciatica pain. Avoid smoking cigarettes since they have chemicals that suppress the blood flow to the lumbar disc.

DO ALL PATIENTS NEED SURGERY ONCE THEY HAVE LOWER BACK PAIN AND SCIATICA AND THEIR TESTS ARE POSITIVE?

No. They must be examined first and a complete history must be taken before deciding that back surgery is necessary. Most of the time back surgery is not necessary and there are alternative measures to be taken.

- physical therapy: This treatment consists of traction, electrical stimulation, ultrasound, deep tissue massage and manual stretching along with specific exercises to treat weak abdominal and lower back muscles that may be contributing to your lower back pain and sciatica pain .

- medication: almost all patients will find some relief with the use of anti-inflammatory medication, muscle relaxants and if the lower back pain and sciatica pain is bad enough narcotic medication. Unfortunately, some patients have reactions to medication that they find unpleasant and do not like to take medication on a long-term basis.

- cortisone injections: very often the pain comes from either inflamed trigger points in the sacroiliac joint which can mimic the lower back pain and sciatica pain produced by a disc problem. Injecting these areas may reduce the pain and resolve the problem. If the problem is much deeper and arising from a damaged lumbar disc with nerve root irritation then a series of epidural cortisone injections may be very beneficial especially if the primary pain is a sciatica pain in the leg.

- manipulation: very minor disc injuries and facet joint mal-alignment can cause lower back pain. Early on in the course of lower back pain manipulation can reset the articular facet joint and frequently diminish the lower back pain.

WHAT IS MEANT BY A "PINCHED NERVE?"

When the nucleus of the disc tears through the annulus it creates swelling, irritation and pressure on the exiting or traversing spinal nerve root. The symptoms associated with a pinched nerve are usually pain in the leg along with tingling, numbness and weakness and this is called sciatica. When there is bowel or bladder dysfunction this should be treated on an emergency basis.

WHAT HAPPENS IF THESE ALTERNATIVE TREATMENTS DO NOT HELP?

You may need to have a surgical procedure performed. The various types of surgical procedures starting with the least invasive are:

IDET- intradiscal electro thermal coagulation
Coblation Therapy
Selective Endoscopic Discectomy(SED)
METRx micro laminotomy and discectomy
Open micro lumbar laminectomy
Lumbar fusion

WHY WOULD I WANT TO CHOOSE SELECTIVE ENDOSCOPIC DISCECTOMY (SED)™ INSTEAD OF THE OTHER PROCEDURES?

Endoscopic discectomy is the least invasive back surgical procedure that can treat significant large disc abnormalities. It selectively only removes the damaged disc material under direct vision leaving normal healthy disc in place to support your lower back. We can tell the normal disc which looks white from abnormal disk which will stain blue with the dye that is injected during the discogram. Only the damaged stained blue disc material will be removed. In this procedure the only cut is a quarter inch incision in the skin. Obtaining access to the disc is performed by slipping the scope between the muscles and ligaments with no cutting of the deeper important structures.

IDET involves heating the disc material with an electric wire. Most patients are worse for several weeks following this procedure and then only about 50% at best have a permanent improvement. This procedure works best for only lower back pain without radicular leg pain.

Coblation vaporizes a small amount of the disc material in the center of the disc and may be successful with a very small disc protrusion by slightly decreasing the pressure in the disc. This procedure is done blindly using the floroscope but the disc material is not visualized.

The other procedures involve cutting muscle, damaging ligaments and chiseling away bone to gain access into the disc. The other open procedures do not incorporate staining of the disc blue because the dye would leak out of the disc during the open procedure. These open back surgery procedures remove normal and abnormal disc and as much disc as possible. This may cause additional weakening of the lower back after the back surgery. On occasion an open procedure is necessary if a lot of bone has to be removed such as in advanced spinal stenosis or if the patient requires a fusion. However, if only a small amount of bone has to be removed this can be performed during the selective endoscopic discectomy with the use of a laser.

MY MRI SCAN SHOWS AN ABNORMAL DISC AM I READY TO HAVE THIS BACK SURGERY?

No. We must perform additional testing immediately prior to performing the selective endoscopic discectomy. At the outpatient surgical facility we must first perform a provocative discogram. This involves carefully placing a needle into the disc space and injecting a safe radiopaque contrast mixed with a blue dye into your disc space. The blue dye will only be attached to abnormal damaged acidic disc material and during the endoscopic discectomy we will only remove the blue stained abnormal disc material. The pattern made by the dye as seen on the X-ray floroscope allows us to determine whether the disc is normal or badly damaged. If the disc is normal the patient will feel no pain. If the disc is abnormal and the source of the patient's pain,  then on injecting the disc the usual lower back pain and possibly leg pain will be reproduced in character and location. This called a positive concordant provocative discogram. Then we can proceed with the rest of the procedure to resolve the lower back pain and sciatica pain. With the needle as a guide we then place a 7 mm YESS endoscope into the disc. We are able to see the abnormal disc material through the scope by using a continuous flow of isotonic saline solution and antibiotics that are flushed into the disk space during the procedure.

I UNDERSTAND THAT THIS PROCEDURE IS DONE WITH LOCAL ANESTHESIA-HOW MUCH PAIN IS ASSOCIATED WITH THE DISCOGRAM AND THE SELECTIVE ENDOSCOPIC DISCECTOMY™?

You are correct, we do the whole back surgery procedure with local anesthesia, however, there is an anesthesiologist who inserts an intravenous line to give you a slight amount of sedation which relaxes you. The amount of medication given is similar to about 1-2 glasses of wine in its effect. He will also monitor your blood pressure and other vital signs during the procedure. You are completely awake during the discogram and the selective endoscopic discectomy and can even watch the procedure on the monitor is you wish.

CAN I BE PUT TO SLEEP FOR THE DISCOGRAM AND BACK SRURGERY PROCEDURE?

No, we need do it with you fully awake and alert so that you can tell us about your pain during the discogram. During this procedure we must pass the needle close to the exiting nerve root. We do not want to injure the nerve and therefore, if we touch the nerve you'll experience an electric pain into your leg. We then immediately adjust the position of the needle to bypass the nerve as we enter into the disc. During the discogram as we inject the dye we need you to tell us if the pain is just like the pain you feel at home. This gives us a high amount of confidence as to which disc is causing your lower back pain and sciatica pain and that the selective endoscopic discectomy will help you. Likewise as we pass the YESS endoscope into the disc we also must bypass the nerve. We need you alert to tell us if you're experiencing any leg pain as we are in inserting the endoscope. If you feel any leg pain we will then adjust the position of the scope to bypass the nerve. As we enter the disc we will inject additional local anesthetic into the annulus to minimize any discomfort. Once we are in the disc most likely there will be no further discomfort.

COULD YOU SUMMARIZE THE ADVANTAGES OF SELECTIVE ENDOSCOPIC SURGERY™ OVER OPEN BACK SURGERY?

1. Local anesthesia is much safer than general anesthesia.
2. There is almost no bleeding.
3. Only the abnormal disk material is removed so there's less chance of disc space collapse after surgery.
4. Your recovery should be much quicker since nothing other than your skin is cut.
5. The endoscope provides more light and better magnification than open surgery.
6. We are able to see the traversing and exiting nerve roots better.

IN WHAT CONDITIONS WILL SELECTIVE ENDOSCOPIC SURGERY™ NOT BE RECOMMENDED?

1. In a rare patient than has a disk that has become a fully extruded and migrated up into the spinal canal.
2. The patient has extensive spinal stenosis he will need an extensive amount of bone removed which is better done with open surgery.
3. If the patient has extensive spinal instability and requires a spinal fusion this must be done with an open procedure.

IF MY SELECTIVE ENDOSCOPIC SURGERY™ IS SUCCESSFUL WILL MY BACK BE COMPLETELY NORMAL LIKE IT WAS WHEN I WAS 15 YEARS OLD? WILL I BE ABLE TO BEND AND LIFT ANY HEAVY THINGS THAT I WOULD LIKE WITHOUT HAVING ANY PAIN?

Unfortunately, once a patient has enough disc injury to have to go through any type of spinal surgery it is not likely that the lower back will be completely normal. You may be totally pain free and not require any medication. However, proper lifting techniques are necessary to prevent recurrent injury to the same disc or other discs in the lower back. Most likely you will be able to participate in most sporting activities as long as you use some prudence. I always tell my back pain patient who have a good recovery that lifting hundred pound bags of cement is not a good idea because the extreme amount of pressure that it puts on the lumbar disc. The degree of your recovery of course will depend upon the amount of nerve damage and disc damage that was present prior to the surgery and your ability to rehabilitate your abdominal and spinal musculature. You may be able to return to your previous type of work but might have to modify the way you bend, stoop and lift to prevent recurrence damage. If your work activities contributed or caused your original disc injury you most likely would have to modify the way you perform your normal work duties. Using a very supportive chair is very important if you plan to return to a job that requires prolonged sitting.

ARE THERE ANY COMPLICATIONS THAT OCCUR WITH SELECTIVE ENDOSCOPIC DISCECTOMY™ SURGERY?

All surgical procedures have potential risks and possible complications and those associated with selective endoscopic discectomy™ surgery are similar but much less common than following open back surgery. The most common complications are:

1-persistent nerve root pain either due to minor manipulation of the nerve or regeneration of the nerve that was damaged prior to surgery.
2-infection may occur in the disc but since the incision is very small and the continuous flow of fluid containing antibiotics and IV antibiotics this risk is very small.
3-persistent back pain may occur to some degree if significant damage to the facet joint was present prior to the surgery. Remember a surgeon can never guarantee that any surgery will resolve all of your problems.
4-minor leg weakness may be present for several months following the surgery especially if it was present for a long time prior to the surgery.
5-occasionally the patient will experience transient headaches.

COULD YOU SUMMARIZE WHY SELECTIVE ENDOSCOPIC DISCECTOMY™ BACK SURGERY WORKS?

Dr. Anthony Yeung has performed more than 2000 of these procedures and originated this technique with the YESS endoscope and taught me his technique. Based upon his experience we believe that this technique is successful because of several factors. The abnormal portion of the disc that is creating internal pressure against the annulus and nerve root is removed. The fissures in the annulus that allow leakage of disc fluid and material are sealed and tightened up with a combination of the use of the Ellman Radiofrequency device and the laser. The constant flow of irrigating saline through the endoscope washes out the irritating damaged metabolites( prostaglandins, histamines,and substance P & X). No deep tissue is cut and generally no bone has to be removed.

IS THE DISC ENDOSCOPE JUST LIKE THE ARTHROSCOPE USED IN MY KNEE SURGERY?

Not exactly, the YESS disc endoscope is longer and almost 7 mm in diameter compared to the arthroscope that may be either 3 or 4 mm in diameter. The disc endoscope has multiple portals that allow the passage of probes and instruments directly through the scope under direct vision. The arthroscope requires the use of additional portals to pass instruments.

DO YOU REPLACE THE DISC WITH ANY OTHER MATERIAL?

Only the damaged disc material is removed. The remaining annulus will support the vertebral body and hopefully prevent collapse of the vertebral bodies. However, some people experience vertical instability of their vertebra which may require an additional surgery to stabilize spine. The only disc replacement becoming available widespread in the near future requires extensive open surgery through the abdomen to replace the entire disc. The disc replacement is felt to be able to stabilize a vertebral segment. The other option would be to have an open spinal fusion with a threaded cage inserted between the vertebrae to stabilize the vertebrea. However, there is significant serious risk of injury to your major blood vessels as well as potential problems with sexual dysfunction in men with this procedure.

IS CHYMOPAPAIN STILL AVAILABLE?

Chymopapain is an enzyme found in papaya that worked by dissolving the damage disc. Unfortunately, in the 1980's it was apparently used inappropriately and in some patients caused permanent severe nerve damage. While the medication is not available in the United States because it is not approved by the FDA, it is still being used internationally. In a very small doses when used with the selective endoscopic technique it may improve the results slightly. I usually do not use this medication. However, Dr. Anthony Yeung will use it on occasion.

I AM 62 YEARS OLD, AM I TOO OLD FOR THIS BACK SURGERY PROCEDURE?

No, I recently successfully performed this procedure on a young(61) year-old waitress who had excellent relief of her leg and lower back pain. Her lower back pain and leg pain (sciatica) had been present for almost 5 years prior to her having this procedure performed. She is now back to doing her normal waitressing job standing all day. I also cured the severe sciatica pain in a 70 year-old grandmother/social worker whose pain had been present for 6 monhts and failed to respond to epidural and foraminol cortisone nerve blocks. However, most of my patients are much younger. Most younger patients have disc injuries that do not involve bone spur formation. Their recovery is quicker.

I HAVE HAD X-RAYS DO I ALSO NEED AN MRI SCAN?

X-rays films only show the bone anatomy and are produced by shooting X-ray beams through your body. Most disc pathology will be shown with an MRI scan followed by a discogram. The MRI scan shows the soft tissue and the MRI is not an X-ray. The MRI scan works because it is a big magnet and you are in it as a magnetic field is created around your body. The magnetic field changes the position of the electrons in the hydrogen atoms of the water that makes up your body. On the MRI scan a disc that is abnormal will look black indicating that this disc is degenerated and has lost some of its water content. This means that it does not have as much elasticity and does not support the the vertebrea as well. This disc can also be called desiccated. The center of the disc is called the nucleus. When too much pressure is applied to the nucleus it can tear or rupture through the annulus which covers the disc. A tear in the annulus is called a fissure or opening and allows the abnormal disk material to escape. Abnormal metabolites can escape through the fissure and irritate the spinal nerves.