Goodbye, back pain

Elizabeth Maldonado had tried all kinds of medical treatments for the chronic back pain that had plagued her since 2005. She saw pain-management specialists who injected her spine with medications and prescribed oral narcotics. After three years of this, she was no better. In fact, she was worse.
Backpain
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Elizabeth Maldonado had tried all kinds of medical treatments for the chronic back pain that had plagued her since 2005. She saw pain-management specialists who injected her spine with medications and prescribed oral narcotics. After three years of this, she was no better. In fact, she was worse.

“The pain became so bad that I couldn’t lift my legs,” says the 54-year-old nurse, who lives in Toms River. “I started to drag my legs when I walked.”

When she was referred to Jonathan H. Lustgarten, M.D., section chief of the division of neurosurgery at Monmouth Medical Center, he suggested a common surgery called spinal fusion. Maldonado had been offered that option before, but turned it down. “As a nurse, I had seen that spinal fusion doesn’t always work,” she says. “But then Dr. Lustgarten told me about some new technologies that would help make the procedure more precise and effective. Then I was more comfortable trying it.”

“Surgery is always the option of last resort,” says Dr. Lustgarten. “And it’s true that it doesn’t always work. But two recent developments have turned this long-established procedure into a new and exciting possibility for some patients.”

Maldonado suffered from spinal stenosis, a typically aging-related narrowing of the spinal column that causes pain by putting pressure on the spinal cord and the nerves that extend from it to the rest of the body. Her spine had narrowed severely and an arthritic cyst was compressing her spinal nerves. She also had some structural dam- age to her spine, which she traces to several falls she took over the years, down stairs and off ladders at home. “Then, in August 2005, I stood up, my back cracked and the pain started,” she says. Dr. Lustgarten says that a spinal fusion procedure often consists of two components: The first is a laminectomy, in which the surgeon removes bone and abnormally thickened ligaments from the spine to relieve the compression on the nerves. The second is fusing the dam- aged area of the spine with bone tissue supplemented by hardware—rods and screws—to provide stability. “These procedures have been done for a long time,” he says. But here’s where the new technology comes in. In the past, the surgeon had to harvest large quantities of bone from the patient’s hip to create the graft. “That harvest can cause pain and increase the chance of complications,” he says. Now, though, surgeons can use only the bone they already removed during the laminectomy by supplementing it with a bone morphogenic (that is, structure-creating) protein (BMP) at the fusion site. BMP interacts with specific receptors on the bone cell surface to encourage bone growth and heal fusions faster. “This is a significant advance,” Dr. Lustgarten says. “Six months after the surgery, you see terrific fusion and much less pain, and that’s often sooner than before we used BMP.” BMP is not used in every spinal fusion, he says. Depending on the site of the operation, it may cause more bone growth than is needed, and it may trigger other side effects. “I use it in about half of these surgeries,” he says. Next comes the hardware placement—and the second major technological breakthrough. A portable computed tomography (CT) scan called an O-Arm helps the surgeon place the screws and rods within the bony structures more accurately. The scan produces images in real time, so the surgeon sees exactly where he or she is during the operation. “And when we’re done, we perform a final scan to prove it’s where we want it, while we are still in the OR, and we can fix it right then if necessary,” says Dr. Lustgarten. “We get a level of accuracy that is beyond what was achieved previously, which means less chance of error or injury to nearby structures.”

Spinal fusion still has a mixed reputation, the doctor concedes. “But I think these two advances put together help us see better pain relief, better outcomes and a higher percentage of pleased patients.”

Count Maldonado among them. The single mother of three children ages 19 to 27 had her surgery on March 23. She says she was pain-free six weeks later and has almost wholly remained so.

“I get a bit achy in the cold weather, and I can’t do all the yoga moves I once did, but I feel great,” she says. “I can do my job perfectly, and I’m an inch taller now that they’ve straightened me all out. I should have done this a long time ago.” New role for a new tool

Two years ago, Monmouth Medical Center became the first hospital in New Jersey to acquire a new computed tomography (CT) scanning device called an O-Arm, which shows the surgeon real-time images while he or she is operating. After performing more than 100 spinal fusions using the new scanner, Jonathan H. Lustgarten, M.D., section chief of the division of neurosurgery at Monmouth Medical Center, and his partners have begun using the technology in a new and exciting way. “We now can do spinal fusion in a delicate area more accurately than we could before,” he reports.

That area is the upper cervical spine where the spine joins the skull. There the brain, spinal cord and critical blood vessels all converge. “Any injury there can be devastating or fatal,” he says. “There is a very low tolerance for any error when placing the screws and rods. Now we can visualize with real- time images and place this hardware with unprecedented precision.”

He and his partners—David Estin, M.D., and Ty Olson, M.D.—have been using the O-Arm since it was introduced at Monmouth. “This new technology allows us to continually refine the way we do both common procedures and more unusual and complex ones,” says Dr. Lustgarten.

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