117- Chiropractic After Spine Surgery

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmead. This week we are talking about a very special patient population in your practice and that is post surgical patients. We're gonna talk a little bit about the surgeries themselves, make sure we have extreme clarity on what's being performed. And we're also gonna talk about the fantastic research showcasing how chiropractic can make a significant impact on on these patients after surgery. But before we get started, I will say a few words as we do each and every week, about Rocktape. Rocktape is revolutionizing the soft tissue world again with new rock blades Mohawk. Featuring three tools in one, a surgical stainless steel hand polish tool and two attachments, a silicon sleeve and an ABS comb. Rockblades Mohawk unlock never before seen treatment protocols to reduce pain, improve mobility and address issues like nerve glide and neuropathy. They're 175 bucks. You can learn more and see all of the educational courses@rocktape.com Mohawk so as I said this week, we are talking about some very, very interesting research and also breaking down maybe a little bit of the haziness or fogginess around some of these patients that come into our practices that are post surgical. So when we take that and start with it, the research shows US that about 2 to 12% of the average chiropractic practice is, is post surgical patients. So that is a pretty good number of people in all of our practices. And when we start to really examine what goes on during those surgeries, I think it's important to set the table with that first. So quite often the most common procedures that many of us see are laminotomies, laminectomies or microdiscectomies. Those can be performed in any area of the spine, typically the lumbar spine. But we see plenty of that in the cervical spine and some of that more and more especially lately in the thoracic spine. And the difference between a laminectomy and a laminotomy is the retention of the superior arch of the lamina. So in a laminectomy that is full north to south, removal of the lamina in a laminotomy that is like making a keyhole in the lamina. And the superior arch is retained so that Is a laminotomy versus a laminectomy. Second to that is the foraminotomy. So we know the foraminal canals are the holes where the nerve root traverse out Half of that hole, the superior aspect is made up of the superior bone, the bottom half of that hole, the inferior aspect, of course, is made up of the inferior bone. And that is a location where the nerve root can be pinched and ultimately cause radiculopathy. So on a paracentral disc herniation, quite often there's a foraminal compression or a foraminal component. So when a foraminotomy is performed, that is sort of the boring out of that foraminal canal to make sure that that nerve root has plenty of room to travel out unimpeded. So that's the foraminotomy. And anytime that the disc is touched, that's typically when the microdiscectomy or the disectomy is tacked on the back end of that. So often that is when the herniated, bulged, extruded, or fragmented portion of the disc is physically removed from the area and then the edge is cauterized to kinda seal those annular fibers and seal the nuclear material in the middle. So that's your laminotomy, your laminectomy, your foraminotom, and your microdiscectomy. When we take it one step farther than that, we can look at some fusion based procedures. Our ACDFs are our anterior cervical disectomy infusions, of course. And anytime that you see a blank lif, a p, lif, a tlif, a dlif, an xlif, that is a lumbar inner body fusion. The first letter is simply telling you the direction that the surgeon took. A posterior, an extreme lateral, whatever the case may be, an anterior. In some cases, you see Alif, Tlif, DLif, anything along those lines, you know, it's a lumbar interbody fusion. Certainly there are a couple other things that have been popularized in the last couple years. One is an X stop device that is an intraspinous device that's implanted between the spinous processes to decrease the ability for the spinous processes to come together, which typically is utilized to open up the central canal. So it's a little jack or a little spacer, if you want to think of it that way, between the spinous processes. If we take it one step farther than that, that would be a coflex device. A coflex device is an intralaminar device. So it goes a little bit deeper than the X stop. And X stop again is intraspinous. So an X stop can be put in or removed. And it does not mean that a fusion has to be performed if a revision is done. However, a Coflex device is similar in concept, only it goes deeper. It's a little jack or a little spacer that goes in between the lamina. So it goes deeper than the spinous processes. Now those also have a little more traction, so to speak. So if a Coflex device is removed, it typically results in going to a fusion. So that is halfway down the road to a fusion. But sometimes the X stops or the Coflexes are used in an attempt to avoid effusion. So that is really breaking down the basics of what many of us will see in practice post surgically spine specific. So when we look at the research related to that and. Well, let's talk one more thing about before we dive into the literature. The other thing regarding this is you have to keep in mind that anytime something is removed from the body, typically it's gonna be ligament, bone and or disc. In these procedures, right, people are going through the muscle, they are removing whatever is causing the compression. And typically that's a combination of osteophyte, bone. It can be some ligament, it can be disc material, whatever is causing the compression that they are trying to take care of. Now here's the catch is that when you take things out of the body, something has to fill in and take its place. So that is where we see scar tissue formation. That is where we see fluid collections that dissipate. That's where we see seromas, encapsulated fluid collections that typically don't dissipate. So the more that is taken out of the body, the more of a cavity is left behind that the body needs to fill. And it is typically filled up with scar tissue and or fluid. So that's why on these post surgical patients, I definitely would recommend taking a look at the pictures. Fluid collections are exceptionally common and you do not want to be hammering in on a drop or a side posture maneuver into a seroma or a fluid collection that's just subcutaneous. That would not be good. So make sure that you check out those pictures post surgically. Sometimes I've seen personally those things stick around, I mean, eight months, a year after the surgery and they're actually still going away just very, very slowly. So keep an eye out for that. So as we know through the literature, quite often, you know, spinal manipulation, chiropractic, care can help millions of people, in my opinion, millions of people avoid ever having a surgery as long as they're able to get in and try. Chiropractic is the biggest thing there. But what we find post surgically is actually a study from just a couple years ago from the Journal of Back and Musculoskeletal Rehab. And they found actually a 55% reduction in disability for those people who had undergone chiropractic care or spinal manipulation post surgically. And in those that did not receive that care, they actually had a 5% increase in disability. So that is a staggering, staggering difference. Additionally, those that were able to have some spinal manipulation post surgically had about a 55% reduction in leg pain as well. I cannot help but feel that that is due to increasing the diameter of the foraminal canal, decompressing the disc. All of the things that we know, the mechanisms of action regarding the chiropractic adjustment and spinal manipulation. So there is no question that chiropractic care, spinal manipulation can be exceptionally valuable for people post surgically. Now, as always, you don't want to go in too early. I worked with one of Johns Hopkins trained neurosurgeons at the last very, very large spine group that I worked with developing some post surgical treatment protocols. And one of the things that we talked about for those who don't have fusions, so let's say our laminotomies, our laminectomies, our foraminotomies or microdiscectomies, those types of things, those patients typically within the first few weeks they're able to do some at home range of motion exercises, so very passive type movements, but starting to establish that range of motion as soon as possible. That's a good thing. The sooner people can get up and walking safely after those procedures, the better off they are typically. And what we were looking at is really about four to six weeks post surgically. Really starting in a chiropractic office at four to six weeks post surgically. We were not starting in with this aggressive active care, but we were starting pretty passive at that point. So large number of passive modalities early in that care, post surgically, then the patient would transition and push forth into a passive and active care regimen. And finally they would be finishing up with a straight up active care regimen. Now, as far as the duration of that care, it completely depends on the patient, right? It depends upon their goals, it depends upon their, you know, pre surg, what kind of shape are they in pre surgically what kind of shape are they in now? But we estimated typically that that post surgical care program could last anywhere from six to 10 weeks, typically in a chiropractor office. And that would be very, very reasonable on somebody who's looking to get back to a pretty darn good quality of life and probably not overdoing it with a rehab. So that would be what we would deem completely acceptable rehab from a chiropract perspective, post surgically. Additionally, I want everybody to know at the evidence based chiropractor, it's all about relationships with other healthcare providers. A lot of times these patients, if they are post surgical and they are having continued challenge, these are people that end up on that medication mill treadmill, the medication treadmill exceptionally quickly. They end up, oh, let's try injections, let's try. I mean this is where a lot of opioids are prescribed, a lot of narcotics are prescribed because the surgeon's reluctant to go back in and do enough procedure. Sometimes they probably had injections before it was done, but they do them anyway. So this is a very key area for everybody. All of you listening. This is a key area to bridge the gap. Post surgical patients are very, very challenging in the medical model and they're challenging for us too as chiropractors. But be confident that the research supports when chiropractic is performed. The goal is we can help these patients avoid any surgical intervention. But those that do go through the surgery, don't hesitate to bridge the gap with of the providers in your community and let them know about what you can do for their patients post surgically that don't get exactly to where they would like to be. It's a great starting point to build a relationship and it's also a great opportunity to truly change some patient lives. If you'd like help with that, check out what we are up to@the evidencebasedchiropractor.com our monthly membership helps you, gives you all the tools, all the resources to bridge the gap A through Z with other healthcare professionals in your community. Nobody does it better, but that's a little bit on the post surgical front. This is a topic I think we can touch on multiple times and go deeper. But hopefully I trust that that gave you a little bit more clarity regarding the surgical procedures that are being performed and some more confidence for patients to be able to get into your office. If they have to go through that surgery, then help them get back to where they want to be. Have a great week in practice and I will talk to you soon.

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