Archive for December, 2015

Freddie Gray Had Spinal Surgery Before His Death?

As most people know by now, Freddie Gray was a resident of Baltimore who died from spinal injuries sustained in the back of a police vehicle. His death led to mass riots in West Baltimore and police officers involved in Freddie Gray’s arrest are currently on trial on various charges related to the man’s death.

Soon after Gray’s death, Facebook was abuzz with claims that Freddie Gray had spinal surgery prior to his arrest. The story appeared on the Facebook page of Baltimore-based Fox affiliate WBFF, the Conservative Treehouse blog, and the Fourth Estate blog. If true, this would have important implications for the police officers involved in the arrest. Specifically, if Freddie Gray had recent spinal surgery that would potentially make his spine vulnerable to injury, and make the police less culpable for the man’s death.

The website thoroughly investigated the claim that Freddie Gray had a car accident and underwent spinal surgery prior to his arrest and death. In short, they determined that this claim was false.

The Facebook story was largely based on insurance records and unnamed sources. The researchers at determined that the insurance records cited by these sources actually pertained to a different Freddie Gray Jr. There are 44 instances of Freddie Gray Jr in the Maryland County database and the settlement cited as proof was linked to a person much older than the Freddie Gray who died in police custody. The Freddie Gray in the Baltimore police case would have been five years old at the time the cited Freddie Gray filed for divorce.

Regardless of the outcome of the trials, there is no record or true account that the Freddie Gray Jr. in question had spinal surgery prior to the incident in April 2015.

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Infection after Posterior Lumbar Fusion (Not where you might think)

Infection is a serious risk factor after any surgery. In mild cases, infection after surgery means a course of antibiotics. Serious cases of postsurgical infection, however, may require admission to a hospital and perhaps a second surgery to treat the source of infection. While most people think of postsurgical infection as an infection in or around the surgical wound, another type of infection is common after posterior lumbar fusion, namely urinary tract infection or UTI. While UTI is not terribly serious in most people, when it occurs in patients after posterior lumbar fusion, it can have quite serious ramifications.

Risk of UTI after posterior lumbar fusion

In a posterior lumbar fusion, the surgeon makes an incision in the patient’s back along the spine. The spine surgeon moves through layers of back muscles and tissues until the vertebral bodies are in view. The spinal bones are fused together using hardware and/or bone grafts. For reasons that are not entirely clear, this procedure increases the risk of urinary tract infection in patients. In one study, 1.77% of people undergoing posterior lumbar fusion suffered a UTI as a result.

 The consequences of UTI after posterior lumbar fusion

Uncomplicated UTIs are rather common and very easy to treat. A short course of oral antibiotics is not enough to cure most cases. However, when UTI occurs after posterior lumbar fusion, it greatly increases the risk for a serious condition called sepsis. Sepsis is a potentially life-threatening reaction to an infection in the blood. In people with posterior lumbar fusion, 11.5% of patients with a UTI experience sepsis compared with 0.6% of surgical patients without a UTI. Moreover, 37% of surgical patients who experienced a UTI after surgery were readmitted to the hospital compared to only 5% of patients without a urinary tract infection.

Risk factors associated with UTI after posterior lumbar fusion

The risk of UTI after posterior lumbar fusion seems to be more common in some patients rather than others. Among these spine surgery patients, those who are older, female, or who have diabetes are at greater risk for developing a UTI. Likewise, malnourished individuals and people who are functionally dependent on others were more likely to develop urinary tract infection. Researchers also found the longer the posterior lumbar fusion surgery took to complete, the higher the patient’s likelihood of developing a UTI.

The reason for hope

While these results are certainly a cause for concern among surgeons and patients, they also reveal a treatable complication that can significantly impact the outcome of posterior lumbar fusion. Since we now know that almost one in 50 patients undergoing posterior lumbar fusion will have a potentially serious UTI, and that certain people are greater risk than others, patients and healthcare professionals can be vigilant for symptoms of UTI after orthopedic spine surgery. Early and aggressive treatment of UTI could presumably reduce the risk of serious infection and sepsis in these patients.

Symptoms of UTI

Urinary tract infection is a clinical diagnosis, which means it is based on symptoms rather than tests. While your physician may perform urinalysis to confirm a diagnosis, a UTI is diagnosed by these three symptoms:2

Dysuria- pain or discomfort during urination

Frequency – urinating more frequently than normal

Urgency – an acute need to urinate arising rather suddenly

More serious cases of UTI may also cause pain around the bladder and blood in the urine. It is important for patients and their physicians to look for UTI symptoms after posterior lumbar fusion surgery and provide effective antibiotic treatment.


  1. Bohl DD, Ahn J, Tabaraee E, et al. Urinary Tract Infection Following Posterior Lumbar Fusion Procedures: An ACS-NSQIP Study. Spine (Phila Pa 1976). 2015.
  2. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? JAMA. May 22-29 2002;287(20):2701-2710.


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When should you NOT have spinal fusion surgery?

Spinal fusion surgery has helped thousands of individuals have less pain, increase mobility, and enjoy life more fully. Nonetheless, spinal fusion surgery is not for everyone. A number of conditions are absolute contraindications to spinal fusion surgery, which means surgery is simply not safe under those circumstances. Likewise, there are number of relative contraindications that may or may not delay a spinal fusion surgery.


Absolute contraindications to spinal fusion surgery

Spinal fusion surgery should not be performed under three circumstances. Fortunately, these circumstances are rare.

  1. Spinal fusion surgery should not be performed on a patient who has tumors in more than one vertebral body such that the surgeon cannot place instrumentation in healthy tissue. In other words, when cancer has invaded a substantial portion of the spine it is difficult, and perhaps impossible, to place the metal hardware along the spine required to fuse vertebral bones together. Simply stated, the surgeon cannot and should not anchor spinal surgery hardware to vertebral bones laden with tumors.
  1. Severe osteoporosis is an absolute contraindication to spinal fusion surgery. This makes sense since the vertebral bones are too fragile to be used to anchor the hardware necessary to fuse the spine. Unfortunately, severe osteoporosis may take years to correct with medication, if it can be corrected at all. This is why severe osteoporosis is considered an absolute contraindication, rather than a relative contraindication to spinal fusion surgery.
  1. If there is any evidence of infection around the spine, spinal fusion surgery cannot occur. More specifically, infection of the soft tissue around the spine or in the epidural space could risk transferring infectious material into the bone itself during surgery. On the other hand, an active spine infection (discitis/osteomyelitis) does not necessarily stop a fusion and instrumentation. In fact, advanced spine infections may be a reason to emergently perform spinal surgery (to stabilize the infected spine).

Relative contraindications to spinal fusion surgery

One of the most important roles for any surgeon is to determine when a person should or should not have surgery. In the case of relative contraindications, this decision becomes more complex. In some instances, usually through medical treatment, these conditions can be corrected to a point at which surgery is safe. If they cannot be corrected, surgery may not be possible.

The eight relative contraindications to spinal fusion surgery are:

  1. Anemia – Strictly speaking, anemia means too few red blood cells in the blood; however, too few platelets (thrombocytopenia) is also a reason to postpone spinal fusion surgery. Both of these conditions can be corrected through transfusion.
  1. Chronic hypoxemia- Chronic hypoxemia is a condition in which oxygen levels in the blood are low and have been for a long period of time. This is usually a consequence of COPD or chronic lung disease (e.g., sarcoidosis, idiopathic pulmonary fibrosis, etc.). Too little oxygen in the blood may interfere with wound healing or increase the risk of complications during the procedure. Less severe cases of chronic hypoxemia may not prevent spinal fusion surgery, though the anesthesiologist usually must help make this determination.
  1. Malnutrition- Malnourished individuals have a difficult time recovering from surgery. Surgery can proceed if the person can regain his or her strength through proper nutrition.
  1. Osteoporosis- Moderate osteoporosis may delay spinal fusion surgery until it can be corrected medically.
  1. Severe cardiopulmonary disease- The heart and lungs must be healthy enough to undergo general anesthesia. In some cases, heart and lung function can be improved through medical treatment making spinal fusion surgery possible.
  1. Severe mental illness- Severely mentally ill individuals, such as people with severe depression or schizophrenia, are unlikely to be able to adhere to preoperative/postoperative instructions and rehabilitation requirements. With proper support before and after surgery, even the severely mentally ill may be able to undergo spinal fusion surgery.
  1. Smoking- Active smoking is a relative contraindication to virtually every surgical procedure that requires general anesthesia. Smoking greatly increases the risk of complications during surgery and delays healing and recovery after surgery. Patients who can avoid smoking prior to the procedure may be candidates for spinal fusion surgery.
  1. Systemic infection – While an infection around the spine is an absolute contraindication to spinal fusion surgery, and infection in another area of the body may also delay the procedure. It is critical that infectious particles, i.e. bacteria, viruses, etc., do not enter the surgical area. In most cases, a person with a fever or other symptoms of infection will not undergo surgery until the infection has been successfully treated.

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Spinal fusion dramatically improves disability, but not completely

There is no question that spinal fusion surgery can greatly improve pain and function in people with certain back problems. For patients who do not benefit from conservative treatments, spinal fusion surgery can be a salvation from chronic pain and disability. On the other hand, it is not realistic to assume that every person with severe spinal problems will be fully restored with spinal fusion surgery.


Better versus normal

Numerous studies have shown that spinal fusion surgery results in improvements among individual patient. In other words, most people who undergo spinal fusion surgery enjoy improvements in pain symptoms, functional ability, and health-related quality of life. However, it is unclear whether spinal fusion surgery actually restores people back to “normal” health and function. New research suggests that people undergoing the surgery can expect to get better, but should not assume they will be “normal.”

Comparing people with back pain to healthy, age-matched controls

Researchers compared the records of 252 spine fusion patients with records of people without back disorders.1 The surgical patients had diagnoses that prompts elective spinal fusion, including degenerative spondylolisthesis, disc herniation or degeneration, spondylolysis, spinal stenosis, postoperative conditions and degenerative scoliosis. The medical record of each patient with a back disorder was matched to a healthy patient based on age, gender, and locality.

Prior to surgery, study participants filled out questionnaires that measured disability and health-related quality of life, namely,the Oswestry Disability Index and the Short Form-36 Questionnaire (SF-36). Study participants then filled out these questionnaires again after that healed from spinal fusion surgery. Scores on these questionnaires were also obtained from the age-matched control group.

Surgery greatly improves outcomes, but fails to achieve perfection

According to the results of the questionnaires, men and women who had spinal fusion surgery enjoyed significantly less disability after the procedure. Though after one year, disability levels were still worse than they were in the general population. Likewise, health-related quality of life improved in surgical patients one year after the procedure, but failed to reach the level of their age-matched peers. Taken together, these results suggest that people who require back surgery will see significant improvements, but will not necessarily reach to the same degree of physical health as people without back disorders.

Surgery restores mental health?

One of the most curious findings of this research was found in the data of the SF-36. The SF-36 has two major subdivisions physical functioning and mental functioning. While surgical patients did not achieve the same level of physical functioning as the general population, the mental functioning results did. As one would expect, a chronic back pain disorder negatively affects mental health; it can cause depression, anxiety, and social withdrawal. This was clear from the low scores on the mental health portion of the SF-36 prior to surgery. Unexpectedly, mental health scores of the surgical group matched those in the general population one year after surgery. While spinal fusion surgery did not restore full physical function or completely eliminate disability, it did allow patients to overcome the mental health consequences of chronic back pain.

Taken together, this means that patients who undergo spinal fusion surgery can expect substantial physical improvement, though perhaps not to the same level as people their same age. Furthermore, spinal fusion surgery appears to fully restore back pain-related mental health.



  1. Pekkanen L, Neva MH, Kautiainen H, et al. Disability and health-related quality of life in patients undergoing spinal fusion: a comparison with a general population sample. BMC Musculoskelet Disord. 2013;14:211. doi:10.1186/1471-2474-14-211

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Physical Therapy or Surgery for Spinal Stenosis?

Earlier this year, researchers at the University of Pittsburgh conducted a prospective trial to compare physical therapy to decompression surgery for spinal stenosis. They enrolled 169 participants, age 50 or older, who were candidates for decompression surgery. The researchers randomly assigned half the cohort to two times per week physical therapy for six weeks and the other half to the spinal decompression group.


Surprisingly, there were no differences between the groups in relief of symptoms or function. In other words, twice weekly physical therapy for six weeks was roughly equivalent to surgery. Participants in both groups showed improvement after 10 weeks with continued improvement through 26 weeks. Both groups maintained significant progress two years after the beginning of the trial.

After two years, physical function (as measured by the Short Form-36)was 22.4 for the surgery group and 19.2 for the physical therapy group (lower scores mean more disability). While surgery outcome scores were slightly higher at the end of the trial, the authors state that these results were not statistically different from one another. These results seem to suggest that physical therapy is as effective as decompression surgery for spinal stenosis.

There are some important caveats to consider, however. While every participant was defined as a “candidate for surgery” by the authors, the fact that half could be treated with physical therapy indicates that the spinal stenosis could not have been severe. If it were, patients would not be able to tolerate physical therapy. Therefore, patients with severe spinal stenosis may require decompression surgery because physical therapy is not an option.

Another point that was not clear from this article is whether patients received physical therapy prior to the trial. The standard of care is to offer patients with spinal stenosis targeted, physician-directed physical therapy before entertaining the possibility of decompression surgery. Does this mean that all study participants had at least one round of physical therapy? Ordoes it mean that no study participants had physical therapy?

Finally, patients who fail to achieve a benefit from physical therapy will likely require spinal decompression surgery at some point, regardless. Therefore, surgery still remains a last resort treatment.

While this prospective study raises a number of important points and emphasizes the effectiveness of physical therapy, it really does not change management of spinal stenosis. Patients who can participate in a rigorous program of physical therapy should do so before trying spinal decompression surgery.

If a spine surgeon recommends surgery before physical therapy it means the patient’s symptoms are too severe to undergo physical therapy, the patient prefers surgery over physical therapy, or the surgeon is not adhering to the standard of care for some reason. If you have mild or moderate spinal stenosis, it is perfectly reasonable to undergo evidence-based physical therapy prior to surgery. If this physical therapy fails or your spinal stenosis is too severe, spinal decompression surgery is still the best option.


  1. Delitto A, Piva SR, Moore CG, et al. Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial. Annals of internal medicine. 2015;162(7):465-473.

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Quantifying back pain: The Oswestry Disability Index

The Oswestry Disability Index is a well-respected, scientifically valid instrument that can be used to quantify the degree of disability a person experiences due to his or her back pain. The questions are relatively straightforward; the complete Oswestry Disability Index questionnaire with adapted scoring is listed below. If you have difficulty with scoring, you may take this questionnaire to your spine surgeon for more information.

Section 1: Pain Intensity

□ I can tolerate the pain I have without having to use pain killers. [0 points]

□ The pain is bad but I manage without taking pain killers. [1 point]

□ Pain killers give complete relief from pain . [2 points]

□ Pain killers give moderate relief from pain. [3 points ]

□ Pain killers give very little relief from pain. [4 points]

□ Pain killers have no effect on the pain and I do not use them. [5 points]

Section 2: Personal Care

□ I can look after myself normally without causing extra pain. [0 points]

□ I can look after myself normally but it causes extra pain. [1 point]

□ It is painful to look after myself and I am slow and careful. [2 points]

□ I need some help but manage most of my personal care. [3 points]

□ I need help every day in most aspects of self care. [4 points]

□ I do not get dressed wash with difficulty and stay in bed. [5 points]

Section 3: Lifting

□ I can lift heavy weights without extra pain. [0 points]

□ I can lift heavy weights but it gives extra pain. [1 point]

□ Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned for example on a table. [2 points]

□ Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. [3 points]

□ I can lift only very light weights. [4 points]

□ I cannot lift or carry anything at all. [5 points]

Section 4: Walking

□ Pain does not prevent me walking any distance. [0 points]

□ Pain prevents me walking more than 1 mile. [1 point]

□ Pain prevents me walking more than 0.5 miles. [2 points]

□ Pain prevents me walking more than 0.25 miles. [3 points]

□ I can only walk using a stick or crutches. [4 points]

□ I am in bed most of the time and have to crawl to the toilet. [5 points]

Section 5: Sitting

□ I can sit in any chair as long as I like. [0 points]

□ I can only sit in my favorite chair as long as I like. [1 point]

□ Pain prevents me sitting more than 1 hour. [2 points]

□ Pain prevents me from sitting more than 0.5 hours. [3 points]

□ Pain prevents me from sitting more than 10 minutes. [4 points]

□ Pain prevents me from sitting at all. [5 points]

Section 6: Standing

□ I can stand as long as I want without extra pain. [0 points]

□ I can stand as long as I want but it gives me extra pain. [1 point]

□ Pain prevents me from standing for more than 1 hour. [2 points]

□ Pain prevents me from standing for more than 30 minutes. [3 points]

□ Pain prevents me from standing for more than 10 minutes. [4 points]

□ Pain prevents me from standing at all. [5 points]

Section 7: Sleeping

□ Pain does not prevent me from sleeping well. [0 points]

□ I can sleep well only by using tablets. [1 point]

□ Even when I take tablets I have less than 6 hours sleep. [2 points]

□ Even when I take tablets I have less than 4 hours sleep. [3 points]

□ Even when I take tablets I have less than 2 hours of sleep. [4 points]

□ Pain prevents me from sleeping at all. [5 points]

Section 8: Sex Life

□ My sex life is normal and causes no extra pain. [0 points]

□ My sex life is normal but causes some extra pain. [1 point]

□ My sex life is nearly normal but is very painful. [2 points]

□ My sex life is severely restricted by pain. [3 points]

□ My sex life is nearly absent because of pain. [4 points]

□ Pain prevents any sex life at all. [5 points]

Section 9: Social Life

□ My social life is normal and gives me no extra pain. [0 points]

□ My social life is normal but increases the degree of pain. [1 point]

□ Pain has no significant effect on my social life apart from limiting energetic interests such as dancing. [2 points]

□ Pain has restricted my social life and I do not go out as often. [3 points]

□ Pain has restricted my social life to my home. [4 points]

□ I have no social life because of pain. [5 points]

Section 10: Traveling

□ I can travel anywhere without extra pain. [0 points]

□ I can travel anywhere but it gives me extra pain. [1 point]

□ Pain is bad but I manage journeys over 2 hours. [2 points]

□ Pain restricts me to journeys of less than 1 hour. [3 points]

□ Pain restricts me to short necessary journeys under 30 minutes. [4 points]

□ Pain prevents me from traveling except to the doctor or hospital. [5 points]

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Mindfulness Reduces Chronic Low Back Pain Symptoms

It may seem like the last thing someone with chronic low back pain would want to do is become more mindful. Traditional medical advice is to do everything possible to get rid of chronic pain: ice an inflamed back, heat sore muscles, take pain pills and injections, or cut away the pain with surgery. Of course, these interventions may relieve back pain in some individuals and they may be quite effective. However, one of the most fundamental ways to deal with chronic pain is to change the way we perceive it. We can change the way we perceive chronic pain through mindfulness.

Acute versus chronic Pain

No one should ignore pain that is new or more severe than it has been. Any instance of new, severe pain should always be evaluated by a physician. This is acute pain and may represent a disease process that requires specific treatment. On the other hand, millions of Americans suffer with chronic pain—a pain that is nearly always present and has been for a long time. Once pain has been evaluated and fully treated by a physician, all that may be left is to mentally deal with that chronic pain.

The psychological side of Pain

Pain is a surprisingly complex process. Bodily pain is straightforward—pain signals travel from a stubbed toe or an arm laceration from the injury to the spine to the brain. This part of the process is similar for most people; however, the way people react to and process pain varies significantly. The severity, intensity, and consequences of pain are affected by our fears, anxieties, and beliefs about pain. Indeed, the expectation of pain (e.g., an impending trip to the dentist’s office) may be more severe than the actual pain itself. By changing the way we process pain, we can hope to minimize it.

The key to Mindfulness

Our perception of pain can be changed through mindfulness. Mindfulness is being aware of the current moment without analysis or judgment. A thought is simply a thought, an emotion is simply an emotion, and a sensation is simply a sensation. Through mindfulness, one strives to separate the beliefs and fears we associate with certain thoughts, emotions, and sensations. Instead, thoughts, emotions, and sensations are simply experienced as they are.

What mindfulness is not

Importantly, people who practice mindfulness are not trying to “clear their minds” or “wish away the pain” because these are impossible. It is impossible to stop thinking or to overcome pain by sheer force of will. While it may seem counterintuitive, people who are trying to practice mindfulness for chronic pain relief are actually not trying to change their pain directly, they are simply experiencing the pain without the emotional and psychological pain attached to it.

Mindfulness Meditation

Ideally, one learns how to be mindful throughout the day, in every moment. Initially, however, people usually begin by practicing mindfulness meditation. Mindfulness meditation takes place for a certain amount of time, say 15 minutes, in which practitioners find a quiet, comfortable space to sit alone with their thoughts and sensations. The person practicing mindfulness meditation focuses on their breathing in an effort to experience the present without wandering thoughts, sleepiness, or boredom.

In clinical trials of mindfulness meditation, 57% of practitioners were able to reduce symptoms of chronic pain. In people who were expert in mindfulness meditation, 90% were able to reduce symptoms of chronic pain. While chronic back pain sufferers should still seek out high quality medical and surgical treatment, mindfulness and mindfulness mediation are effective at dealing with the day-to-day struggles of chronic pain.

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