(light music) – Hi, I’m Susan Taylor at Scripps Health, in San Diego, California. How many times have you said, oh, my aching back, you turn the wrong way,
you’ve got pain down the back, in the muscles, the bones,
may be pain down the leg? Here to talk about what to
do for your painful back and the technological advancements that have taken place in back surgery, are Dr. James Bruffey, he is the associate division head of orthopedic surgery at Scripps Clinic and the medical director for the spine care line at Scripps Health, and one of his patients, Mark Erwin. The former triathlete, you
were sidelined at the age of 40 because of back problems, you gave up running and golf, and you couldn’t stand
for more than 20 minutes without pain, nothing
not a good place to be. – No, it was not a good place to be, and I’ve known Dr. Bruffey many years now. And you know at the time I had this, so we could still do
the things you wanna do, but when you really get pain, where you really can’t do
the things you wanna do, and I was still skiing,
riding my bike, swimming. He said come see me, so I did and I got to the point where I really couldn’t do anything. I was in pain all the
time, and that’s when, you know we did the
first surgery on my back. – Well Dr. Bruffey, let’s
go back for a second, when should somebody seek
medical attention for their back? I mean obviously, you might
get pain lifting up a stroller or maybe you’re taking
care of your parents, and you’re lifting up a wheelchair, or you’re working out too much at the gym, how do you know when it’s
just pain that’ll go away, and you should go see the doctor? – Right, that’s a tough question because most back pain episodes
are indeed self-limiting, they go away on their own. I think for most patients
they kind of know what’s a strain, and what’s
probably more significant. And if they don’t, it’s
probably reasonable to at least seek some medical attention with their primary physician at least, depending on the severity of symptoms. – What causes back pain? – Oh gosh, a little bit of everything. It can be muscular, it can
be the joints of the spine, the discs are part of that joint complex that forms the motion
that allows our spine to move, essentially. You can have nerve compression
from arthritic conditions, and from other things. So there’s a variety of reasons
why the back would hurt. – And so the point when you
should go see the doctors, if you have the following what? – Well, I mean there’s certain things that obviously if there’s
a neurologic change in your status, you need to
go see the doctor right away. – So if you have numbness or? – Numbness, weakness, change
in bowel or bladder function, those are the kind of the red flags that we look for when we do
an exam and take a history. – Pain that doesn’t resolve
in what period of time? – Generally, most self-limiting
back pain episodes are about 24 hours to 48 hours, they’ll start to feel better
within that period of time. – So, Mark what happened? You were you were a triathlete, you were a very active guy. – Yeah, and I gave up running and golf, those are things I think, I think the first or the
orthopedist that looked at my back said, I looked like I had
a congenital back defect at L4, L5, and that my
vertebrae weren’t formed totally at that point. So I was taking more pounding
than normally one would take, and but you know, I was used to it. I mean, you get like Dr. Bruffey said, these things kinda come, they go away, and I thought well, I’m not gonna run, I’m not gonna play golf,
I can give that up. I could swim, ride my bike, I could ski, and as long as I could do those things you know, the trouble was
if I had to go to an event and stand for any period of time or go shopping, was like kill me first. You know, I don’t wanna go shopping, find a place to sit down. But over time it got to the point where you know, it was really limited. I mean, I really got to the point where I really couldn’t even, you know even getting in the pool and swimming, and moving my arms above my head hurt, so you know, it was obvious
that something had to be done. And the neat thing at that
point, the technology, it really progressed from
probably the first time I met Dr. Bruffey to the point where there were really, really good options. – Yeah, I think you’re right. – But you talked about
there’s like spine shifting, and you know, aging, genetics, arthritis, this is common right, for folks over the age of 40? – Yeah, it’s really, really quite common. There are varying patterns
of the way we develop wear and tear on our backs, and so Mark had a fairly
common version of that in his lower back. Conditions, words that you’ll
hear if you see your doctor, spondylolisthesis, sounds– – There’s a mouthful. – It is, but it’s a shift in your spine, and it’s generally from
arthritic changes in your back, and so Mark had one of those, where the spine bones had shifted due to long-term arthritic changes. And unfortunately, as a byproduct of that Mark also had what we call stenosis, which is the narrowing of the nerve canal, and where the nerves
come out of the spine. So his spine was actually
compressing on his nerves through that arthritic process. – So why don’t you show us, with the spin that you have there, what you did with Mark. – So, for Mark, this is
obviously the operated on spine in a model form, Mark’s condition we had attempted to do a lesser operation to just make room for the nerves, and that shifting process
actually won the battle for Mark. It actually recreated symptoms within about about a what? A year, year and half? – I think a couple years.
– A couple years? A couple years, we got two years out of a non-fusion operation, but for Mark his main problem became the instability from his arthritis. So what we did for Mark was we are using a technique now, we realized to better fix the spine, to get it back to where it was, we’re realigning things as we go. So, a surgery done from
the front of the spine, it gives us access to the disc spaces. They say why do you rob a bank? That’s where the money is, we do spine surgery, and we go to the disc spaces because that’s where we can achieve the best effect in terms of getting our fusions to heal, and getting the spin realigned in it’s more in atomic position. – So show us. – So for Mark, we used an incision coming through his abdomen. Gives us access to the front of the spine, or the discs, we place spacers, which you can see on the model here, there’s little plastic spacers. They’re not little actually,
they’re quite large. They’re held in with
varying fixation devices, this particular model has one with screws, and then one with just little
teeth on it that hold it in. And once those are in, that actually does
probably 90% of the work, it actually restores the alignment, pulls the spine bones back
into their normal position. Which takes the pressure off
the nerves in many cases, and then the same surgical setting, through separate incision on the back, we’re able to place this
relatively fancy-looking, titanium set of instrumentation in. Which then, essentially
this acts like a brace on the inside, so you don’t have to externally brace anymore. The work is done through
the screws and rods that are placed in this spine to hold it. – So back surgery of 15-20
years ago compared to today, 15-20 years ago surgeons just
went in through the back, you didn’t go in through the front, right? – Well, there were surgeries done, the anterior procedures, or the tummy based approaches were done. The technology has evolved now so that we were able to
get more reliable healing, and we have implants and devices that really allow us to
tailor make the solution to an individual’s problem. So if a space is narrowed, we have narrow, wider spacers, depending on the access
that you have to the spine. We have better solutions, so we are getting better results. – My gut instinct says if
you go in through the back, it’s not as traumatic as if
you go in through the front. And you’re saying it’s just the opposite, right?
– Exact opposite. So in the posterior
operations that we used to do, you still had to get the spine to fuse, so that involved essentially
taking the muscle off of all the back of the spine, taking a bone graft material, often from the hip, and then packing that onto the bone that we’ve
roughened in the operating room. So it was pretty traumatic
to the back muscles, very traumatic to the back muscles. We would still use this same type of screw and rod system to hold the spine, but it was much more traumatic. Now all of the bone
grafting is actually done through the anterior incision, through the front.
– Through the front. – And it’s held within these devices, are essentially hollow, so we’re basically able to put bone grafting
material inside of there. So it makes it way less traumatic to actually get the fusion to heal. So you’re doing way
less surgery in the back because now we’re just
simply splitting the muscle to place these rods and screws,
that’s what Mark had done. – And how does that
speed up recovery time? – Well Mark, you can
probably address that. – Yeah, I was walking the same day. I think I was in the
hospital about three days, I was able to go up down stairs. You know, and I’d say that the the most challenging part about the recovery wasn’t
so much the surgery, it was just you know the
anesthesia takes a while, ’cause you’re under for like
four and a half hours or so? – Yeah about that, four and a half. – That was probably the
hardest part at first, but I was you know,
walking down the street, you know within a couple days, around the block you know, within a week. You know, within two weeks, really I was out of the woods. I mean, it was still healing a lot, but I really didn’t have, I mean, I had like no pain at all. – Which was pretty wild.
– I mean, at all, yeah. And of course, when I came out of surgery, I forget which time, I was talking to Dr. Bruffey, and I said gee Dr. Bruffey, you know boy, why me kind of thing, I was thinking about that. He says well, if you looked
at what you’ve been doing the last 60 years of your life, and I thought yeah you got a point there. Yeah so, I’ve been very active but my back has not felt this good in as long as I can remember. I mean, more than thirty years. I mean, I got to go back
to when I was in my 20s to when my back felt this
stable, and this good. – How lovely is that? – It’s a miracle, it really is. – I appreciate that. – So it’s what, two to
three days recovery, when you’re up and walking? Compared to ten or fifteen years ago it was a lot longer, wasn’t it? – It was a lot longer, yeah.
– Five to ten days? – You could be in the hospital
for a week or two previously, we would shorten our hospital
stays depending on technique. Obviously, we’ve all gotten better, every surgeon within the system is doing this type of surgery now. So you know, the the recovery
time has been shortened dramatically, the hospital stay time has been shortened with
the better technology we have available and
the better techniques. – Very cool. In a couple of minutes
were gonna talk about what you can do, what
steps that you can take to actually preserve your back. Let’s hold on to that thought, we’ll come back to that in
just a couple of minutes. Mark you’ve said that you’re
not running anymore, right? What have you had to give up and why? – Well, I gave up running, you know when I was 40, and early on in my career I was with Nike, and I was in that business so it was fun. But I you know, always had
some issues with my back because it was off a bit, and so I could never run more than a certain number of miles. But, so that was a limitation. Golf, you know I played
a lot of golf as a kid, then as I grew older I kind
of didn’t wanna spend time doing it, so those are
the two main things. And now, I probably can really, I’ve skied a lot my whole life, and swimming was my weakest in triathlon, but it’s what I do the most of now, so I mean, I love swimming. And you know, so I really at this point, I could probably do most
anything I wanted to do. I really have no interest in running, I’m not that interested
in cycling anymore, I’ve ridden so many miles, and never been hit by a car, I just again, the odds
are not in my favor. But I think as far as
the things I want to do, which I swim masters four or
five days a week you know, and you know a pretty demanding program, and I could easily go back
to skiing if I wanted to. I’ve been going to Maui
instead of skiing lately, and swimming in the ocean, but yeah I don’t really
have a lot of limitations. You know, we’re gonna
take the hardware out, which should improve my
shock attenuation on my back, so you know, I’m conscious
of not wanting to put too much pounding on my back. But running, you know like I said, no interest really in running. But really, I don’t feel like I have limitations at this point. It was interesting the associate that was working with you, and you know, because I was
looking at recovery time, and stuff and I figured three months. I think I was back in masters in about, you know within six or seven weeks, you know, I was back in
the pool within two weeks. – And master swim, explain
to everybody what that is, it’s very aggressive swimming.
– Well master swimming, it’s basically an adult, post-college, organized swim team workout. It’s like a team swim. So you’re doing three to four
thousand yards of workout. – [Susan] You’re really pushing yourself. – Yeah, I mean, different days, different things. But yeah, I mean most people look at it, it’s really demanding. I mean, compared to some of
the bike stuff I used to do, it seems shorter but you maybe in the pool for an hour and 20 minutes, and you’ve swam a couple
miles, what have you. But, so that and you know, I do a
lot of walking and stuff with my dog and so I really don’t have, at this point I don’t have limitations. I mean, I’m conscious that I’m lucky that I’ve got my back back, so to speak, and I’m not going to do anything that really would hurt it. – Let me key off of that, somebody who’s had back
surgery, Dr. Bruffey, should they continue if they want to do, you know hard pounding, like running? And then also, talk about how you’re gonna take the hardware out too, – Sure.
– Which sounds wild. – Actually, so we’ll go
with the first point. I try and encourage my patients to go back to what they liked to do. Obviously, for Mark we were forced to stabilize his spine,
so we had to fuse levels. It’s a compromise, right? We can’t restore the anatomy, much like a hip replacement, as a replacement of a hip joint. But it’s metal and plastic, so it has certain limitations. We can’t replace the native spine, I can’t make it like
it was when it was 20. I’m glad it feels that way. – A little stiffer.
– Right, we’re gonna try and help that. So with that we could go back to the instrumentation
removable part of it, but the idea being is that you’re trying to create stability where your body has developed arthritic instability. – When you say fuse the back, what do you mean by that? – So we’re essentially going to take away the motion between Mark spine bones, and previously where
these plastic inserts are, the spine would move. – [Susan] And that’s where
the discs were, right? – Discs were.
– And everybody has those discs in their spine.
– Everybody has a disc, there’s five lumbar discs, there’s 12 thoracic discs, and seven cervical. – [Susan] And as you age those discs start to kind of get
wear and tear on them. – Correct, they don’t have
a good lot of blood supply, so they start to develop
their degenerative changes, probably when we reach skeletal maturity. And then, there’s
genetics and environment, you know wear and tear
plays a role as well. – And running 50 miles a
week doesn’t help, you know. – Yes, for some of us, the combination of
running 50 miles per week plus genetics.
– Or golf, look a Tiger, yeah. – Yeah right.
– So you’re getting rid of that disc space? – Well we’re restoring the space. The spacers actually, the plastic inserts, restore the space height, so we’re restoring the bone alignment, but we’re taking away the motion. So that makes the spine stiffer. Now for Mark obviously, that trade-off created an enormous
amount of symptom relief, and that’s pretty typical
for most patients. They’ll generally trade the stiffness they feel in their back, for the pain, and the nerve compression that Mark was getting
100% percent of the time. They’ll definitely take that stiffness. – Absolutely.
– It’s a different feel. – And then, talk about you’re gonna take what hardware out? – So right, so the
instrumentation that’s removed, is what we, for certain patients, Mark had to have three
levels of his back fused where he had arthritic change, so the stiffness of the titanium rods, the screws are just
holding places in the bone, it’s the rods that are holding the spine. They’re stiffer than the spine is, in fact the titanium’s about 200 times stiffer than the bone. So for the short term, I found that that’s extremely helpful in to getting the fusions to heal in the positions that I want them to heal. In the long term, I found that patients complain of that sensation of feeling that, they can feel that. Not everybody does, so I talked to every patient about if they feel that or if they feel like they have any residual
discomfort in their back, we make sure everything’s healed, and then we have the
option of removing that. It’s a relatively small operation, we do it as an outpatient. – Really?
– Yeah. – [Susan] So they come in in the morning
– Then go home. – [Susan] They have the
surgery and they go home? – Correct.
– That day? – Yes, because the new techniques allow us to do this through
small incisions relatively, that we split the muscle, so we can just split it again, take everything out now. It’s much harder to put it in than it is to remove it. It all disconnects from itself, and then we can take it out pretty easily, and pretty atraumatically. – And then how long does it take to heal, what do you need to do after
the hardware’s taken out? – So that’s all just soft
tissue healing at that point, all the fusion has healed, and so for Mark it’s two
weeks out of the pool again to let the incisions heal up, and then back to his normal routine as the muscle trauma from
the certain new surgery allows him to go back. Most people are back to almost
full unrestricted activities four to six weeks. – And if he wanted to run, I mean, after you have back surgery, can you go back to resuming
your normal lifestyle? – You can, you can run, you can golf. I have patients that do that all the time. There’s a caveat, so once you have a level of your back that’s had to be fused or operated on, even if you don’t fuse it, you are putting stress
either at that level because it still moves or now you’re transferring
stress to the other levels that are doing the work that
the fused one no longer does. You’ve taken away that motion, so theoretically, you will
place the other levels of your spine at a slightly higher risk of developing that same
degenerative change, and ultimately become symptomatic, and bother you again so you’d have to have potentially, other surgeries done. – So then what kind of
exercise would you suggest somebody does after
they’ve had back surgery? – Well, it’s really pretty
much the same as before. So we should always be
working on our flexibility in our trunk, in our back, and our legs, and our hips, we should
be really focusing on low-impact aerobic activities for our cardiovascular health. – Like swimming?
– Correct. – [Susan] But you wanna go
back and ski, is that correct? – Yeah, skiing I don’t
think would be a problem. – [Susan] Does he get the
green light for skiing? – He does, and unless he
falls a lot when he skis, that’s a pretty low impact activity. – Don’t worry, I don’t fall. (laughing) – This position of skiing, I’ve had other patients tell me this, the position you’re in for skiing is very well tolerated. – Yeah, it’s very comfortable, and especially if you’ve done it your whole life.
– Yeah, right. – So, that wouldn’t be a problem. – And so for the other things, you want to work on your core strength, so keep your abdominal muscles, and your back muscles strong. – Which swimming is great for. – Yeah that’s right, I couldn’t have written
a better exercise program for somebody post-op than Mark. – [Susan] What about surfing? – Surfing’s hard on one’s back. But I will be honest, I
treat a lot of patients in San Diego County that’s surf, and I want them to go back and do that because that’s a passion for most of them. And so our goal is to
make a durable improvement in their spine health, so that they can go back
and do those kind of things. And I think all my surfers would agree that they’re willing to take the risk. They like being in water. – We talked about this
a couple of minutes ago, what advice would you give folks to help take care of their back? What preventative steps can you take to basically preserve your back? – Right, well the exercise becomes key, making sure you’re doing the right things from an exercise, and
flexibility standpoint, on a routine basis. You have to take a vested interest in your own health at that point, and really start to do things that help your back stay
strong and flexible. You work on keeping your weight down, that’s obviously very important because you’re putting less
load on the structures. If something hurts while you’re doing it, reassess that. You know, I mean you may want to change. As I’ve gotten older, I’ve had to change my activities as well. You just have to take a hard assessment of if something you’re doing is painful, you probably need to rethink it. – What about stretching? You know, doing core exercises? I’ve always heard that if you strengthen your stomach muscles, that
actually helps the back. – It does, your core muscles, your back extensors,
your abdominal flexors, your entire abdominal wall musculature, is an additional support
structure for your spine. Which is taking the load
from gravity, as well. So that helps dissipate
that load within the spine, so very important to do that. – And if you’re leaning over to pick up the stroller, or leaning over to pick
up weights at the gym, is there a certain way to do that? – Well there is, obviously
we all make mistakes as we lift and bend. Bent knees, hips flexed, tightening your abdominal muscles before you go to lift something heavy, those are the things
that will help prevent or limit your ability to hurt your back during that activity. But it’s really the preventative
medicine I think of, keeping your back strong and flexible, that prevent you from
injuring it theoretically, as you’re doing those type of things. – What about stretching, you know major stretching like yoga? Does somebody need to do
with that kind of stretching in order to keep the back healthy or what kind of stretching you talk about? – I think everybody picks
their own stretching routine. Yoga’s a great activity for getting flexibility and strengthening. Pilates is another one. Those are very good supervised activities, or structured activities you can do. But the internet’s wonderful, you have all kinds of
access to simple things that you can do at home
that are all accessible just through simply doing a web search in terms of looking at exercises
and that kind of thing. And if you’re having
pain, see your doctor. We can get you into our
physical therapists, so that they can work with
you and your individual needs, and then come up with a program at home that you can then do. – You had back pain for
how many years, Mark? – Oh more than you can count, I mean – Decades. – Decades, yeah, yeah.
– Okay. – And, even you know, little
things like in swimming, I would cramp, my left calf would cramp after a number of yards, and it was related to my back tightness. And that’s pretty much all gone away, and I think the fact that I’ve always been an athlete, and I’ve always, you know kind of done the right things. probably kept me from having surgery for a really long time. – [James] Yeah they did. – And I think it really helped in my recovery, as well because I would tell people to just whatever Dr. Bruffey tells you, do exactly what he says. (laughing) And if you do that, you know you got to go slow at first that’s just, you know which
people tend to be patient, I’m getting more patience as I get older. But if you do exactly what he says, everything he told me pretty much came the way he said it would come. And I think you or your associate said I would get stronger for four months. I thought three months, I feel great, but I kept getting stronger, and I kept getting stronger. And part of that I think is
just recovering from the trauma, the surgery, and the anesthesia. But I you know, it’s a miracle, and Dr. Bruffey’s a rock star in my book, I mean he really has made
a difference in my life. – Appreciate that.
– A big difference. – Yeah, appreciate it.
– And when you look down the road what do you see? – Oh, you know I could pretty much do whatever I want to do, and I think getting the hardware out, and I don’t feel a thing, I look at that and go,
oh my god, that’s in me? I don’t feel a thing. I’ll probably have a little
bit more flexibility. – As we hope.
– A little more shock attenuation, I’ll be
a quarter pound lighter, which I know I need to worry about. But I think it’s just giving
me kind of my life back, to do all the things I want to do, whatever is I really want to do. And if I wanted to jog or something, I walk more, and running just
doesn’t interest me anymore. And I was a pretty elite cyclist, was a good runner, I did a lot of extreme
athletic things with the bike, and you know, I’m never gonna get better at any of those things, but swimming I still get better at. So, for me it’s cool that I can improve at something that I’m you know, doing a lot of, now more than I’ve ever done. – What’s the goal, Dr. Bruffey, that you have for all your patients? – Oh, to get back to what they had before. You know obviously,
there’s always limitations. Again, I’d love to be able to say that I can make you better than, you know, make you back to perfect, but that’s an unrealistic goal for me. But to give you back your quality of life so that you’re not in a daily amount of discomfort or pain, or limited in ways that are really meaningful to you, that’s where I like to
see my patients end up. Is they can come in and say, I’m able to do the things I want to do with way less discomfort and way better level of function. – Yeah, and I have like no
discomfort at all, no pain, and like I said I can remember even back when I was competing in
triathlons in my early 30s, my back would get sore and stiff, and I think it was related to things that were not just quite right, and I don’t have any of that. So, part of its my lifestyle now too, but a part of its my back
is aligned perfectly, and I got taller too. – I know you like that as a side effect. – I think about an inch or so. – I know, it’s pretty amazing. – I got my height back, yeah. – And that’s from inserting the the disc, that the stuff in the disc space, right? – Yeah, it’s combination of the spacers restoring the alignment, and actually literally,
realigning the spine back up to where it needs to be, or where it was probably 20 years ago. Yeah, and one of the theoretical benefits from Mark, is he’s so active. I worry that the stiffness of that instrumentation long-term will put more stress at the level above, so Marc’s not having any symptoms, and I think we’re trying to
get head of that game too. We’ve talked about that. – Well, one final question, so if you have back surgery you know, here, let’s say the
lower part of the spine, which is where most people
– Very common. have it?
– Most yeah, very common. – And then, you put in that hardware, does it then stress the spine further up so you end up having subsequent
surgeries down the line? – Well, it can, it doesn’t always, and so, you know one of the things if you’re a surgical patient,
and you’ve had surgery, we’ve talked about
modifying your activities, and Mark’s doing that to kind of put less stress on the areas. But also to check in with your
doctor if you’re having pain, that’s one of the things
that I found beneficial in my practice is to say,
okay can I get the patient then to heal and then can
I reduce the stiffness long term by doing something
simple like this for Mark? And I do it for other patients as well, who want that material removed,
the instrumentation removed. I think it theoretically
reduces the stress long-term, it certainly makes sense
biomechanically, so. – [Susan] Any final thoughts? – Well I think, I’m just really grateful
that this procedure, and I know Dr. Bruffey, and that you know, I’ve got my life back and it’s humbling in some ways, you know to know that I’m
the beneficiary of all this, and I’m extraordinarily grateful. – [Susan] Dr. Bruffey, any
finally thoughts from you? – Gosh, no, I’m just
glad you’ve done well, I mean, I think that’s what
I want for all my patients. – [Mark] Well, I had the
best doctor, how could I not? (laughing) – No, sometimes I get lucky. – You’re humble, you’re humble, you are. – Yeah, it’s humbling job, so yeah. – Thank you both so much. We wish you continued good health. – Thank you, Susan. – Send us some pictures when you’re down the he
double-black-diamond mogul on the ski slopes, okay? – Maybe from Maui first, yeah. – Okay, thank you.
– Yeah, exactly. Yeah sure, thank you. – At Scripps we have more
than 135 board-certified orthopedic surgeons to take
care of your bones and muscles, and Scripps is consistently ranked by US News and World Report as among the nation’s
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