Navigating Surgical Options for Recurrent Disc Herniation | Podcast Ep. 427

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we are back with more research, a brand new study in the annals of medicine and surgery. This is all about recurrent lumbar disc herniations. And it's a comparative analysis between posterior lumbar future fusion P lifts or repeat disectomies or microdiscectomies and how this shakes out over time. Really, really great information for us to know on the conservative end of the care continuum because it helps us inform our patients better when they come to us with questions about what's going on. And subsequently, when we do see patients that have previously had surgical intervention, we can better guide and direct their care. Before we get started, I'll say a few things about Patient pilot by the smart chiropractor and we've made some massive upgrades to patient pilot over the last month or so, including sending all of our docs, all of our members, the names of the individuals who are looking to reactivate in your practice. We send weekly email newsletters with big buttons. I say click to schedule, call to schedule. They teach and invite each and every week. So if you have a patient list of 500 or more and you're not continually reaching out to them, you're missing an opportunity for revenue in your practice. That revenue comes through reactivating the people who know, like and trust you. Those are your past patients. Chances are you probably have if you look at your database, maybe you have 500, maybe you have a thousand, maybe you have 2,000. How many of those patients are active? I'm going to say probably 80%, 90% of your patients are inactive. That is a massive opportunity. You can take advantage of that in an automated fashion. Head over to the smart chiropractor.com hop on a demo with our team. Ask any questions that you want. The smart chiropractor.com but as I said at the top, we're talking research. This study came out this year. It is a brand new study and it is titled Management of Recurrent Lumbar Disc Herniation A Comparative Analysis of Posterior Lumbar Interbody Fusion and Repeat Discectomy. I'm going to drop a link down to this in the show notes. If you want to check it out yourself, you can head on over and it takes a look basically comparing P lifts, posterior lumbar interbody fusion to to disectomy and says what's going on with this? Hey, when somebody has one of these surgical procedures done Is there any difference in what happens in terms of a recurrent disc herniation in the future? So as people age, we know this becomes more of an issue. Degenerative disc disease, facet joint disease, arthropathy, all of these things are super common in the lumbar spine and they all contribute to to low back pain being the number one cause of disability worldwide. It's just the way it is. Why is that the case? For some of the reasons. Amongst what you've heard me say on this podcast in the past, which is there is the instantaneous axis of rotation, that centerpiece motion of the disc migrates posteriorly over time. That inherently loads the facet joints. You add to that postural issues, imbalances, structural changes, previous injuries, and what do you end up with? A body that's aging, there's nothing wrong with that, but it often comes with pain and changes. Doesn't have to, but those tend to be the outcomes, especially with previous injuries and all of those other items. So typical symptoms associated with, you know, disc injury is mechanical back pain, radicular pain, claudication symptoms, reduced mobility, poor quality of life. We see it all, each and every day as a result of disc issues. And disc herniation is a common result or manifestation of degenerative changes to the spine. And it's typically managed in the medical realm through discectomy techniques. This could be open surgery, it could be microdiscectomy, it could be an endoscopic disectomy. All of these are applicable. An endoscopic dissectomy simply means a tube is used. A microdiscectomy, you still might use slight retractors, but potentially not a tube. In open surgery, as you can imagine, is what you'd believe it to be, which is a larger scale incision, a larger retraction, and more of an aggressive procedure. So previously it's been noted that recurrence rate of a disc herniation following discectomy can be as high as 30%. Let me say that one more time. Recurrence rate of a disc herniation after a discectomy can be as high as 30%. Yes, you heard that correctly. That's astounding. Most patients, most of the time have no clue that that's the truth. Let's be honest, because if you knew that there was about a one third chance, most people believe, let's be very clear about this. Let me say a different way. Almost everybody out there believes that surgery is going to, quote, unquote, fix their problem. 1/3 of the time minimum, one third of the time. Because there are other things that can happen to make it unsuccessful. One third of the time, the same exact problems comes back. That's a big deal. We're also going to talk about the fact that you can't just keep working on the same disc without advancing to effusion. That's a really big deal. They also highlight the fact that instability rates post discectomy are around 25%. So we have a recurrence of a disc herniation happening about 30% of the time. We have instability or progression towards instability about 25% of the time. Those are big numbers and a big deal. Especially when people are mostly sold on a discectomy to avoid a fusion procedure, when in reality, maybe not a majority of the time, but a good chunk of the time, they're actually moving their way closer to a fusion by having this. Because of those numbers we just talked about what are some of the risk factors for disc herniation? Recurrence. Couple things that they've identified over time. Smoking, a younger age, actually, which is interesting. Being overweight and increased discipline, disc height. Now, let's also be clear with a couple of those items. Smoking just tends to be a risk factor for just about everything. Being overweight the same way, it just creates structural load beyond what the spine would like to have happen. Therefore, no surprise that we see occurrence rates and or instability rates happen when you're taking stuff out. Right. Whenever you do a microdiscectomy, you are removing pieces from the body. The challenged pieces, of course, the disc itself, amongst other tissue. It's impossible to only remove disc. You pretty much have to touch other aspects. Obviously you have to make a decision on the skin. You have to go between the muscles. If you're not suturing on the way out, you at least need to split them. That causes trauma. You may need to get around bone or ligament to get to the disc. And the only way to do that is to drill your way through and to make sure that you're removing things along the way. And that is what creates a precarious situation on an overloaded segment. Once you get out of there. And you might have removed where the disc is pressing on the nerve, but you've compromised the integrity of that segmental unit. That's a really. That's a play. I mean, that's a chance right there. And that is why we see, or at least part of the reason why we see these recurrences and instability happening. Increased disc height is interesting. I want to Point out the fact that during a fusion based procedure, the whole disc is never removed. A surgery would take eons, it would take days. You wouldn't live through the surgery if somebody removed every portion of the disc. So even when somebody's removing a disc and putting in a cage, removing a disc and putting in a implant as part of a fusion based procedure, it's very rare that more than 50 to 75% of the DISC maximum is taken out. It just would take too much time. So you take out a majority or as much as you can of the offending portion of the disc and then you put the implement in there as well. And the reason you have to put the implement and the hardware on the backside is because by definition you're doing that because it's either an unstable segment to begin with or you're taking out so much material that it will be an unstable segment in the future. So those are in. And there are some exceptions to that. In the cervical spine, if you approach anteriorly, pretty much the only way to do that is with a fusion based procedure. If you approach posteriorly in the cervical spine, you have the opportunity to do a laminectomy or a laminotomy or a disectomy, as they'd say here. So a little bit off topic there, but just to give you some context into how do these procedures kind of shake out over time. I worked in orthopedic group, I worked in a surgery company, so this is the stuff I lived and breathed all day, every day for a number of years, and got to see the good, the bad and the ugly associated with it. So the good news about dissectomies is that typically they are recommended because they are more minimally invasive. They also have shorter hospital stays and they can be more cost effective than a fusion based procedure. But they still carry re herniation risks. They still carry risks that they could advance into unstable territory which will result in a fusion over time. Fusion techniques, obviously more expensive, longer hospital stays, but they do generally. I've seen a couple exceptions to this, but generally speaking, they do eliminate the risk of recurrence at the same level. But you end up with adjacent segment disease because anytime you're fusing a level, you're overloading by definition the segments above and below. And usually the segment above plain English goes bad over the next few years, especially if it wasn't perfect to begin with. So all really important things for you to keep in mind as a chiropractor when you're taking care of people, maybe Again, they have questions about these types of procedures. Hopefully their surgeon should be giving them the best answers possible. But it's also really nice for them to be able to lean in and lean on you, especially if they're making that tough decision and they've come to you first. Being able to help guide and direct it with accurate information is really important because it's not always that they're going to get the most accurate information in another doctor's office. So doing the best you can for your patients is a really good job, a really good idea. The other thing is you're going to see patients, of course, that have had previous surgical intervention. So understanding what the risk factors are, what the rates look like, help your clinical decision making as these patients come in looking for help. Now, interesting aspect. In this study, a dural leak or a dural tear was the most common complication for both a microdiscectomy and within the scope of a fusion. And that stood at almost 38%. That is insanely high. That's all I know. It's just insanely high. So it was 37% for the disectomy group and it was about 12% for the fusion group. That's a really big deal. Now, most of the time a dural leak can be stitched or it can be left alone, or sometimes even almost glued, so to speak. But it also can create a really, really big challenge. I mean, headaches, there can be hematology, I mean, there can be a lot of challenges associated far beyond what we can get into today related to a dural leak. So it's a really big issue and it's happening really often. When we look at nearly 30, 38% and then nearly 12%, this is happening a lot. It's important that people be aware of that. Now, the disectomy group, as we've highlighted, was associated with the recurrence rate in this study of 22.5%. There were no recurrences at the same level. Let's be clear about that, at the same level when a fusion was performed. So of the 40 patients that underwent disectomy alone, not fusion in the study, 22.5% had a fusion surgery during the follow up period because of a recurrent issue. So it was like over a 1 in 5 chance, 1 in 4, 1 in 5 chance that if you had a microdiscectomy, you were gonna be going back and having a fusion. And that's a really, really big thing. Now, of the patients that had a disc herniation recurrence. In that discectomy group, nearly 89% had Modic 2 changes on the preoperative MRI. I'm not saying that that's a, and they're not saying either that that's an abject predictor, that. But it's an interesting thing for further researchers to take a look at. Is, are those modic two changes preoperatively leading to or increasing the likelihood that a microdiscectomy won't work? I don't know the answer to that yet, but it's an interesting note also, 83.3% of patients experience progressive degeneration after a microdiscectomy. I'm gonna say you live long enough, probably 100% of them there. But many people, an overwhelming majority, will have degenerative changes. So, and it's really also important to note we've highlighted this briefly, but I want to circle back around to it, which is anytime a fusion is performed, yeah, you're not going to have a disc herniation. Very rarely you'll have a disc issue at that level. But you're really increasing the possibility of adjacent level herniation. And adjacent level disease can happen, you know, 25, 35 plus percent of the time. And now you start to end up in many cases with that cascade. And this is what you really want to be careful of. And this is what people want, want, want to avoid, but many aren't. They're electing for these surgeries like a microdiscectomy, earlier than they should or before. They've exhausted conservative options, which leads towards this direct path. And I teach about this every time I'm on stage. And it's so direct, somebody goes in. It doesn't happen every time. And this isn't an indictment of every doctor out there, but this happens all the time. Let's just be super clear about it. Patients go in with a radiculopathy, they have an mri, they take pain medication. The pain medication doesn't work, they get injections. The injections work for a short time and or not at all because they have radiculopathy caused by a disc herniation that's shown on the MRI microdiscectomies performed, 25 to 35% have a recurrence of that or they have instability. Then what do they end up with with a fusion based procedure? So if we want to talk about costs, and this is very rarely have I seen this cited, everybody wants to look at costs on a case by case basis, meaning case value in other Words. Well, they came in for a fusion that cost this amount or they came in many times. These things are compounding over time. So the PCP is prescribing the medication, the pain management doctor is getting paid for the injection. None of this is working. The microdiscectomy didn't work and now they're not a fusion. And now once they get a fusion, now you're increasing your likelihood of adjacent segment disease, which increases the likelihood they're gonna stack onto that fusion. Now, thankfully this doesn't happen in like 90% of people, but it happens way more than it should because it almost should never happen. If somebody's really going through their care algorithms, if they're really taking into account what's going on patient, and quite frankly, let's just be straight about it, if they are referring appropriately to chiropractors and really instituting movement based care earlier on, as opposed to what I call medicalized care, AKA advanced imaging, medications, injections, et cetera, this makes a massive difference in the outcomes for what happens to individuals over time. Also just important to note, blood loss is associated with fusion based surgeries and it's higher than a disectomy procedure, of course, because you're cutting through much more tissue that's going to create a lot more blood loss. So the conclusion was in this study, the fusion a P lift and repeat discectomy for recurrent lumbar disc herniation have comparable in this case intraoperative blood loss. So fusions tend to have more. In this study they were about even duration of surgery and hospital stay. Now plif is associated with lower dural leak rates and better long term pain control they highlighted than a dissectomy. The pain was much greater on the fusions right after the surgery, but it dissipated with the amount of discectomies that went on to have a fusion or recurrence of challenge. They had more pain over a longer period of time. So nothing that we don't know, but an interesting study, just kind of highlighting and reiterating what we do know. And that's some of the most important things that we can keep our eyes peeled for. A lot of times we highlight chiropractic research on this podcast. We'll continue to do so. We've got some great studies lined up, but I also like to highlight things that we just need to know about, which is what's going on with our patients outside of our practice. The more that we're aware of that, and specifically relative to the spine musculoskeletal neuromusculoskeletal care. The more that we know about that, the more that we can engage with our patients, chat with our patients and let them know when they ask us informed questions, we can give them informed answers. So as we wrap up, I want to say a few words about stemwave. If you're looking to add shockwave therapy into your practice, I cannot recommend stemwave high enough. You can go to gostemwave.com the evidencebase chiropractor that is go stemwave shawnwave.com the evidence based chiropractor. Hook up with their team, ask questions, hop on the phone with them and I cannot again, I can't recommend their technology enough and if you head over to that link, I'll drop it down in the show notes. Just stimulate a conversation with them. They're going to hook you up. They are supporters of this podcast. I'm going to ask you to support them. If you're looking to add in Shockwave into your practice, stemwave is the way to go. Finally, if you're looking to add a virtual assistant into your practice, a virtual ca. No, this is not AI. It's an actual college educated specialist. Head over to Chirometric makers, schedule a vca, a virtual chiropractic assistant, a VCA call with the team over there. I use their virtual assistants myself and it is a massive game changer. Like 70% less cost than somebody in the in the practice. Totally trained up on what you need, whether it is social media management, whether it's answering phones so you never miss a new patient call, whether it's insurance verifications. This is a massive opportunity that is going to take the medical world by storm and you can get ahead of that curve right now. For Penn, head over to chiromatchmakers.com I hope you have a fantastic week in practice. Thank you for listening and I will talk to you soon. Thank you for joining us on this episode of the Evidence Based Chiropractor. If you want to grow your practice, come back for next week's episode. If you want to grow faster, visit theevidencebasedchiropractor.com and join our MD Marketing membership today.