Neck Pain & Spine Surgery with Brett Gunter, M.D.

Neck pain is a leading cause of disability worldwide and it can affect your ability to work and participate in activities you love. In this episode of Advance with MUSC Health, Brett Gunter, M.D., a Neurosurgery Specialist at MUSC Health, Columbia explains how surgical treatments, such artificial disc replacement, may offer lasting relief for patients. His neurosurgical expertise is in brain disorders, spine and peripheral nerves.

"It's like taking a flat tire off your car. You can take the tire off the car, but if you don't put your spare back on, you still can't drive your car. Essentially a disc replacement is a full-size tire just as close to the one you had to begin with. And that's the goal behind (artificial disc) replacement, is to restore mechanical components to the disc space that simulates normal physiology."

Topics covered in this show:

• Gunter explains that most people with neck pain won’t need surgical intervention, but if the spinal cord is compressed or a nerve root is compressed to the extent that surgical decompression is necessary, spinal fusion and artificial disc replacement are the two options for patients.
• Artificial disc replacement is a newer approach in the U.S. Gunter was involved in early clinical trials for disc replacement that lasted for 15 years and he says it is an excellent option because it simulates normal physiology and allows patients to move their neck normally.
• When choosing a spine surgeon, Gunter says it is important to ask about both spinal fusion and artificial disc replacement. He says if a surgeon won’t discuss both options, you should get a second opinion.
• Artificial disc replacement success stories Gunter has seen includes fellow surgeons who had the procedure on a Friday and were back to doing surgeries the next week and professional skiers who were able to return to the slopes within days of surgery.

Read the transcript below:

Erin Spain, MS [00:00:04] Welcome to Advance with MUSC Health. I'm your host Erin Spain, this show's mission is to help you find ways to preserve and optimize health and get the care you need to live well. Neck pain is a leading cause of disability worldwide, and it can affect your ability to work and participate in activities that you love. New surgical treatments, such as artificial disc replacement, may offer lasting relief for patients. Here with more details is Dr. Brett Gunter, a neurosurgery specialist at MUSC Health Columbia. His neurosurgical expertize is in brain disorders, spine and peripheral nerves. Welcome to the show!

Brett Gunter, M.D. [00:00:44] Hey, thanks a lot.

Erin Spain, MS [00:00:45] As a neurosurgeon, you see many people with chronic neck pain. What causes it and when should people seek medical care for this type of pain?

Brett Gunter, M.D. [00:00:54] Well, most of the patients who come in to see us have degenerative condition, cervical spine illnesses, degenerative diseases, it goes by a lot of different names. And for the most part, the three things that influence this condition are your age, how you were made and how you live. If you were in some traumatic event, you might have a higher risk of having a herniated disc. Let's say if you're older, you have a higher risk of the effects of wear and tear. And of course, if your family has a long history of back and neck problems, you may also be subject to that. So your age, how you made and how you live really influenced this condition.

Erin Spain, MS [00:01:29] So neck pain is the third most common type of chronic pain around the world, and it causes disability. Tell me about the impact that chronic neck pain can have beyond just the patient and how they feel.

Brett Gunter, M.D. [00:01:43] The financial impact to the population is substantial just from loss of time at work and loss of productivity in the workplace. And of course, the most individual experiences that you just lose the enjoyment of your life because your life is consumed by pain and suffering related to the conditions that we're going to discuss today.

Erin Spain, MS [00:02:03] Well, yeah, let's talk about that. So cervical disc degeneration is this common condition that we just brought up can cause pain not only to the neck and shoulders, but that arms and hands too and can lead to numbness. So tell me how you treat this condition.

Brett Gunter, M.D. [00:02:18] We try to use a nonsurgical approach, even though today's topic is mostly about surgery. Most patients will never see surgery. The cervical spine, the closest degenerative cervical disc, is a very general term, so it has many forms. If you present to your physician with neck, shoulder and arm pain and no significant neurologic findings from your physician and their teams if it produces neurologic compromise of significance and instead of going into all the different ways that can be able to say neurologic compromise of significance, and if surgery is indicated in the majority of patients, you won't need surgery. And most of these conditions can be self-limited, especially with a little help from your physician if it produces neurologic compromise of significance. Usually, it's because either the spinal cord is compressed or a nerve root is compressed to the extent that surgical decompression is necessary.

Erin Spain, MS [00:03:12] And so how do you typically treat this condition through surgery?

Brett Gunter, M.D. [00:03:15] In the patients who are appropriate for surgery, as I mentioned, all the non-surgical treatments need to be used first whenever appropriate. It's not appropriate in every case, but whenever it's appropriate, we try to use nonsurgical means. But when a patient has a surgical indication that usually the reason we do surgery is to take the pressure off either the spinal cord or the nerve roots, and really disc replacement and fusion are only necessary considerations because we have to restore the disc space to some mechanically appropriate condition. So it's like taking a, you know, flat tire off your car. You can take the tire off the car, but if you don't put your spare back on, you still can't drive your car. So essentially a disc replacement is a full size tire just as close to the one you had to begin with. And that's the goal. Behind disc replacement is to restore mechanical components to the disc space that simulates normal physiology.

Erin Spain, MS [00:04:10] How has this technology of the artificial disc? How has it evolved in recent years?

Brett Gunter, M.D. [00:04:16] Artificial disc replacement technology started really in Europe, and it's probably 40 years ago now, and it's been a long time, especially in England. The story from England I know pretty well there was a number of attempts in England to create a nice artificial cervical disc. And because of the difference in medical liability and the lack of an FDA and all those things over there, they were able to really move forward with lots and lots of different prototypes. In my case, I became involved in disc replacement technology as an investigator in a randomized, prospective clinical trial that accrued about 250 patients in each group, I believe. The trial lasted for about 15 years and went from about 2003. A 2018 or so in that trial, we studied fusion patients at two levels, and that means two cervical disc were removed and they refused. And we also studied disc replacement patients at two levels. Two cervical disc were removed and the patients received a disc replacement. The patients were randomized to receive one treatment or the other, so they had to accept both treatments. Then they knew which one they were going to get, but they were randomized. And so my experience is largely shaped by this scientific observation that occurred over the course of this 15 year trial. About two years into the trial, I realized that if I had to make a choice between disc replacement and infusion, there's no question I would choose disc replacement if it was appropriate. That choice, that decision, that that reality for me increased and became enhanced as the study continued to progress. And so for me, while fusion is still probably more common, certainly more common in this country, disc replacement is the choice that I would make if I were the patient. So when we see patients, we offer both treatments and we just discuss things that we know based on our observations, which I've done about 2500 cervical disc levels now with disc replacement and probably that many with fusion as well. We discuss with patients our observations, our personal observations professionally, but there's also a good bit of information that's level one scientific data, randomized prospective clinical trials, multi-center for a number of different devices out there. And they all essentially show the same sorts of things that this all the trials showed the disc replacement and fusion were about the same in terms of their ability to control neck pain and cervical riddick allopathy, which is the Sheldon arm pain, numbness, tingling, that kind of stuff. But this replacements allows you to continue to move your neck normally and fusions limited your ability to move your neck, especially at that level. In my opinion, cervical disc replacement reduces the risk of adjacent segment disease, which means that it reduces the likelihood that the level above and below a disparate placement will need to have future surgery. It doesn't eliminate it because this is a wear and tear disease, so it's going to occur, and a disc replacement at one level is not going to stop you from wearing out a level above or below. It simply reduces that likelihood of wear and tear to something that's near physiologic, whereas the cervical fusion seems to be more likely to produce a adjacent segment where

Erin Spain, MS [00:07:17] So if someone has to get this when they're a younger person, does it wear out over time? Is there any data there that people might need to have another one down the road?

Brett Gunter, M.D. [00:07:25] If you look at artificial disc replacements like the one I've used, I mean, it's probably been implanted in human beings since, I don't know, maybe 2005. So at the most, there's a 17 year experience, so we've never had one been somebody for their entire lifetime. So how would you know the answer to that? Well, because it's a mechanical device where it can be simulated in the lab. So essentially what you do is you you count the number of times that we bobble our head around and you multiply that by the number of years that you live in a normal lifespan and then you subject the device to that much bobbling, let's say. And then you pull the device out and you go, Well, did it wear out or not? And so for the most part, none of the devices ever showed enough where to be concerning to me, at least, and I think they shouldn't be concerning to a patient. They all show wear. After all, it is a frictional force disease, and so it will eventually produce somewhere. My belief is that the devices will last for a lifetime, and even if you had one implanted at a very early age, let's say 18, for some reason, my expectation is that the device would last your lifetime expectation based on laboratory study and not and people studies, but in laboratory studies, is that the device will last you a lifetime.

Erin Spain, MS [00:08:39] Let's talk about the patient experience. Let's say you are a candidate for the surgery. You get the surgery. How long does it take to experience pain relief and tell me some of those success stories?

Brett Gunter, M.D. [00:08:50] So the easiest success stories are the ones where you do on your coworkers, you know, and I've got a lot of coworkers that I've done this surgery on. And so I've done, you know, disc replacements on surgeons who had surgery on Thursday and were able to go back to do surgery on Monday, which I thought was exceptional. Probably more than I would do is. I'm not so sure I'm tough enough for that, but I've had coworkers who were able to have surgery come back to work in two or three weeks. I did a disc replacement, a friend of mine who did remarkably well, and he's essentially he's a competitive skier and I went right back to doing that. So I think you could be active for me and my patients. The difference in recovery is significant in that future in patients who sort of need them to be immobilized a little bit. We need them to that level to not be stressed or forced too much, whereas it's actually your rehabilitation to resume your normal activities with disc replacement. So we encourage you to resume your normal activities more quickly. Of course, some of this is a matter of practice like a few better, more than one doctor you've seen more than one way that medicine can be practiced. But in my practice, I encourage the disc replacement patients to resume normal activities and move their head and neck because we want them to do that.

Erin Spain, MS [00:09:54] When patients are suffering from chronic neck pain, many use opioid medication, which can lead. Two dependence and other issues. So after you have this artificial disc replacement, are people still using those kind of powerful painkillers?

Brett Gunter, M.D. [00:10:08] How much narcotic a patient uses after surgery is somewhat influenced by how much they use before surgery. If you have a patient comes in who's got chronic pain, true chronic pain and they've been on chronic narcotics. They're not just going to magically stop when you do any kind of surgery. That's a necessary and difficult step to get them off of those drugs because they're habit forming and they have other physiologic problems. But most patients come in. They've had pain, probably not even realistically considered chronic, but they have an excellent arm pain or symptoms related to spinal cord and compression. Most people experience pretty significant relief in the recovery room before they go home. I would say 75 - 80 percent, probably more than that. Most of the time, for a single level disc replacement, it's about as about an hour long surgery. And they usually go home about three hours later and they resume normal activities as quick as they're willing to. So I don't want them the next day to not take any pain. Medicine to get up and get going to little disc replacement might take an hour and a half. Essentially, the recovery is a little saying that because it's two levels, the surgery is longer and the effects of the surgery, which are which are negative, are difficulties with swallowing and some hoarseness and things like that and that are usually transient. But that all comes from the fact that we cut your neck in order to in the front to do the surgery. But usually the patients go on the same day from either one or two little disc replacement.

Erin Spain, MS [00:11:28] Explain the difference just for those listening between the one and two level.

Brett Gunter, M.D. [00:11:32] If you have just one disc level that's got producing an indication for surgery, let's say it compresses the spinal cord and nerve roots. Then we're just going to remove that disc. And so the amount of your spine that we have to expose with surgery is less is just enough to do that one thing. But if there's more than one level that has that same sort of problem, let's say one level produces spinal cord compression, another level produces nerve root compression. Then you have to expose two levels. So the surgery takes longer. So the amount of retraction that you're swallowing to your esophagus and your breathing tube, your trachea, the amount of retraction or hold against force on your structures, like your trachea and your esophagus and your voice box, and the nerve that gets your voice box is all of longer duration and all more likely to produce post-operative symptoms.

Erin Spain, MS [00:12:22] Now, let's talk about that a little bit. You mentioned a few things that could be post-operative symptoms, common side effects, or things that you see that you know, that happen as a result of this surgery that are not optimal. Can you share those with me?

Brett Gunter, M.D. [00:12:35] So hoarseness is less common, and it's usually not very significant. But when it does happen, it can take a while for it to get better and retraction on the voice box and the nerve that leads to the voice box or even injury to the nerve that leads to the voice boxes is a potential complication. There are more serious complications which are very uncommon, probably difficulty swallowing. I would say every patient who has an anti or cervical exposure is going to have some trouble swallowing after surgery. The question is is to what extent and how long? And so some people, it's just for a few days and other people for a few weeks, and other people say a few months and other people's prolonged Andrew to the nerve spinal cord injury to the major vascular structures of the carotid artery in diggler vein will be right next to where you do surgery. You know, if you're an experienced by a surgeon, then you know those structures are part of why we get so much training and part of why it takes so long to do what we do.

Erin Spain, MS [00:13:30] So what should people look for in a spine surgeon if they are in need of this surgery? What should they look for?

Brett Gunter, M.D. [00:13:36] Well, the first thing I want to communicate to patients is that you have a choice about whether you get a fusion or a disc replacement. Make sure your surgeon discusses both these days. I think a lot of surgeons don't give disc replacement enough consideration. So if I'm going to find a surgeon, obviously I would ask around and find out, you know, do you have friends who had been treated by him? I'm a big fan of a personal recommendation from somebody else who's been treated. You want to have a good relationship with your surgeon. You want to get the sense that they're paying attention to you, that you're important to them. You want to learn about what their complications are. I would look my surgeon right in the eye and say, OK, well, what complications have you had from doing this procedure? What would you choose yourself? Make sure you ask those questions. You know, how many of these have you done? So I would urge the patients to ask their surgeon if their surgeon dismisses disc replacement, get another opinion, find somebody who will offer you a disc replacement and fusion, and then you studied the options and then you make a choice with your surgeons help and with your family's help and your friends or whoever you have this knowledgeable but don't just accept a fusion which we cannot undo. Once you've had a fusion, you're done, OK, there's no going back to Oh, I wish I had a disc place. I'll go. Have one of those could I could ask that question all the time? We cannot undo that.

Erin Spain, MS [00:14:54] What is your philosophy as a physician, as a surgeon?

Brett Gunter, M.D. [00:14:59] So my surgical philosophy is basic first, avoid surgery if you can try to get everybody better without surgery, when you do have to do surgery, have a clear understanding of exactly what you intend to accomplish in these surgeries. You generally want on pitch the spinal cord of the nerve root and then you want to restore mechanical sufficiency. that third, when you do have to restore mechanical sufficiency, try to spare motion, try to keep the patient in a normal physiologic state.

Erin Spain, MS [00:15:27] What do you do to optimize your health and live well?

Brett Gunter, M.D. [00:15:31] I think the most important thing I've done lately is lose weight. I would say weight loss is critical for me personally. My blood pressure became normal. It was never really high, but it was heading the wrong way. My blood sugar went back to a better way so I could ask everybody to do one thing. I would say try to reach your ideal body weight. Man, I struggle with it because I have a sweet tooth. And so if it were up to me like I'd be eating a piece of cheesecake during this podcast, feel as if it was permissible, but you have to do the best you can.

Erin Spain, MS [00:16:02] For more information on this podcast, check out at advance.muschealth.org.