When It Comes to Spine and Neck Surgery, a Conservative Approach is Best

Surgery is an excellent tool for treating back and neck pain, and MUSC’s team offers the most advanced techniques for patients. Not everyone who is experiencing pain, however, requires surgery, says Dr. Robert Ravinsky, attending orthopedic spine surgeon and assistant professor in orthopedic and rehabilitative medicine at MUSC Health. We spoke with Dr. Ravinsky about MUSC’s innovative surgical techniques, his philosophy regarding treatment and care and other treatment options available for patients with spine and neck pain.

How have spine and neck surgeries changed In recent years?

A. Many advances have been made. Innovative technologies have made spine and neck procedures safer, more precise and more efficient. With each passing year, we also have a better understanding of surgical indications and who would benefit from certain treatments or procedures.

Q. Please describe them.

A. At MUSC Health, we have developed a very big platform for enabling surgical technologies, including navigation and robotics. Both navigation and robotic surgery, when used correctly, can make surgery safer because they allow for a high degree of accuracy, particularly for implants and in the placement of screws. This helps us deliver high-level care and perform complex surgeries as safely as possible and confidently, especially when abnormal anatomy is present, or if the patient has had multiple operations.

With specific regard to what robotics and navigation means, the robot uses a high-resolution computed tomography, or CT scan, to place screws precisely via the robotic arm. We also have two O-arms, which assist with navigation in surgery and overall make our procedures safer. The O-arm fits over the surgical table and takes an intraoperative CT scan, or three-dimensional picture of the spinal anatomy, in real time and allows us to make adjustments during surgery if needed.

The O-arm also interfaces with a navigation system (guided imagery) if needed. This technology has a lot of different applications and improves safety and surgical precision overall.

Q. Does this mean that older techniques are no longer used?

No, the basic principles of spinal surgery do not change even if the technology does. Innovation, however, allows for the development of new techniques and also can allow us as surgeons to consider the use of older techniques that went out of vogue because of problems. But now those problems have been solved and we can revisit these techniques that can be done to help patients with certain problems.

No, the basic principles of spinal surgery do not change even if the technology does. Innovation, however, allows for the development of new techniques and can allow us as surgeons to consider using older techniques that went out of vogue because of earlier problems that have been solved, thus helping patients with certain problems.

Q. Please give readers an example.

A. One good example of this is sacroiliac joint fusion. The sacroiliac (SI) joint has historically been a poorly understood part of the body, but it is recognized as a cause of back pain in some patients. In the 1970s and 1980s there was a huge interest in treating this with open sacroiliac fusions. The problem was twofold: First, the operation was incredibly morbid and caused a fair amount of injury to normal tissues, and second, we did not have a good sense of who would benefit from this procedure.

Today, we have far less invasive techniques for doing SI fusions, and we have evidence-based guidelines that help ensure that this procedure is offered only to patients who are likely to experience pain relief and improved function.

Q. Explain what is meant by fusion surgery, and why you try to avoid fusion surgery.

A. Spinal fusion surgery refers to the insertion of surgical implants that afford stability across a moving segment. It creates a biological environment where bone can grow across the motion segment, thereby turning two or more separate bony structures into a single “fused” segment of bone. Fusion surgery can in some instances help patients greatly, but it does have its downsides and must be used judiciously.

A fusion will diminish the range of motion in the spine and can cause other issues in the future, which can lead to additional surgeries. We perform it only when absolutely necessary.

Q. You’ve mentioned alternatives to surgery. When do you recommend these and why?

A. A lot of problems in the neck and back can be treated without surgery and, if there’s a good way of doing so, I will recommend them first because it is always better for the patient. Some patients who come to me with neck and back pain have never tried any conservative treatment options, and they are the ones I encourage to try other modalities before turning to surgery. My colleagues and I try to exhaust all the conservative options and do surgery only when it is necessary.

Will you elaborate on your conservative approach?

In general, spinal surgery is probably over-utilized in the United States, although I believe this has improved in recent years. However, the fact that so much unnecessary surgery has been done in the past has led to a lot of failures and patients seeing spinal surgeons for salvage procedures.

This can lead to many operations in a patient’s lifetime, which can take a physical, mental and emotional toll on patients. We can do our patients a favor by exhausting all other options when possible. My partners and I are focused on treating patients conservatively, giving patients value and doing just enough ─ not too little, and not too much. These are the core philosophical tenets that we feel strongly about and make every effort to live by.

What treatment options are available?

Physical therapy is an excellent option because core strengthening can improve cervical and lumbar spine pain. A physical therapist who understands core strengthening and pathology can be immensely beneficial for patients.

Other options include:

• A self-directed, physician-guided home exercise plan that a physical therapist would use.
• Over-the-counter pain medications such as Ibuprofen, Tylenol and Naproxen
• Topical medications, Diclofenac topical cream, lidocaine patches
• Applications of heat and ice
• Injections such as cortisone, or in other cases, ablations
• Manual therapy, including chiropractic care, acupuncture and dry needling
• Psychological counseling and anti-depressants in people who have anxiety or mood disorders

Q. Psychological counseling seems like an unusual recommendation for spine and neck treatment. Why so you recommend it?

A. Back and neck pain can have a psychological component. Anxiety, social isolation and psychological stress can intensify back and neck pain. To a large degree, this can be improved with counseling or certain medications.

Q. What patients make the best candidates for spinal or neck surgery?

A. Patients who have failed non-operative treatments and for whom surgery will provide a better outcome are the best candidates for surgery. I also believe that you will get your best surgical results when the patient history and physical examination tell the same story as the imaging and investigations. I treat patients as young as 15 and 16 and in their early 90s. Back problems and neck problems affect people of every age, from every segment of society.

What do you tell your patients about surgery?

A. I will lay out their options and discuss drawbacks and advantages. It’s important for my patients to have input, so we can talk about their values, their risk profile and their goals. My job is to allow the patient to make the best decision for their goals and lifestyle.

Is the number of people suffering from back and neck pain increasing?

A. I think spinal problems, and back and neck pain have increased. We lead a less active lifestyle than we did in decades past, and inactivity is a big problem, even among younger patients. Many young people who come to my office are healthy but overly sedentary. Furthermore, in my practice, I see many patients in their 70s and 80s who wish to maintain an active lifestyle, which I think may be a general trend compared to 20 years ago.

Q. What would you tell readers about spine pain and surgery?

A. I would say that spine surgery is an excellent tool when the other tools are no longer working. Try conservative treatment first. A huge amount of experience and judgment goes into picking the right operation for a patient, so it’s important to discuss goals, needs and demands of lifestyle with a doctor. That helps a surgeon determine what the best is the most appropriate treatment for a given patient.

Q. Why should a patient choose MUSC for spine and neck treatment?

A. MUSC is well-positioned to treat every spinal condition. We have incredible access to technologies and resources that are unrivaled in South Carolina, and we have a team of doctors and health care providers with a tremendous breadth of experience in treating the most complex conditions. Additionally, our conservative approach and dedication to evidence-based practices distinguish us. Everyone who works here is committed to providing the best possible care for our patients.

Dr. Ravinsky sees patients at MUSC Health Orthopaedics, West Ashley Medical Pavilion, 2060 Sam Rittenberg Boulevard; MUSC Health Nexton Medical Park, Suite 320, 5500 Front St. in Summerville, and MUSC Health Chuck Dawley Medical Park in Mount Pleasant. To make an appointment at one of these 3 locations, call 843-876-0111.