Autumn is prime time for shooting sports and anyone who has spent a morning in a duck or deer blind has likely experienced some back aches and pain from handling a shotgun or rifle during a hunting trip. While this is expected for older men and women who only get out in the field a few times a year, this back pain resulting from shooting can affect younger shooters as well – even when they are Olympic champions.

The back specialists at Texas Back Institute treat many injuries caused by strains caused by shooting every year and Dr. Richard Guyer has some insights to help infrequent hunters avoid this back pain. Before you grab your gun and gear, you might want to give his advice a shot!

Back Injuries Threaten the Career of Olympian

According to the USA Shooting TeamSarah Scherer, a 2012 Olympian was forced to withdraw from the 2014 World Shooting Championships in early September as the result of a back injury. This condition prevented her from training properly and would have kept her from traveling and competing without significant pain and limitation of her shooting.


As with most athletes in this sport, Scherer has dealt with minor back pain throughout her career, but it worsened significantly in August 2014. According to news reports, pain from three herniated discs was so severe that she was sent home early and placed on an aggressive physical therapy program in hopes of getting her ready to compete.

All that effort proved insignificant in treating the pain and condition and thus Scherer, in consultation with the U.S. Olympic Committee medical team lead by USA Shooting sport physiotherapist Cathy Arnot and Dr. Bill Moreau, ultimately decided the best path was to not compete and aggressively treat her symptoms with surgery likely in the near future.

Scherer was a two-time NCAA National Champion in smallbore (.22 caliber) rifle at Texas Christian University while also leading the Horned Frogs to two national team titles. At the 2010 World Championships, she was a junior silver medalist in three-position rifle while teaming with Amanda Furrer and Sarah Beard for a team title. She earned a bronze medal in three-position at the USA World Cup earlier this season in Ft. Benning, Georgia.

According to the USOC medical team, Scherer has two disc extrusions- one at L3-4 and one at L4-5 and a disc protrusion at L5-S1. The end result is pain, loss of muscle function and sensation in her legs and an inability to get into shooting position without creating more pressure on the spinal nerves. Her symptoms have not responded to high dose steroids or physical therapy. The likely next steps for Scherer will include spinal injection, and a probable spinal decompression at the affected levels.

Prognosis for the Olympic Shooter


For a young woman, who has world-class conditioning and impeccable shooting form to be sidelined by these types of back injuries suggests a high degree of risk of back pain for those shooters who are older, perhaps out of shape and likely have less-than-world-class form.

“Sarah’s situation was likely caused by genetic pre-disposition in combination with the extreme wear and tear of constant training and competing,” Dr. Guyer noted. “Most weekend hunters don’t have her form and stamina, but they also don’t shoot nearly as much as she does.”

Could this type of injury be career-ending for the young shooter?

“Having not seen the x-rays, it’s impossible for me to say,” said Dr. Guyer. “However, if there is leg pain associated with this condition it is more serious. If so, a microdiscectomy, where a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement to allow the nerve to heal,  would possibly be in order. If her pain is centered only in her lower back, she might be a candidate for disc replacement because of her age and activity level. Fusion would be a secondary choice,” he noted.

How Hunters Can Avoid Back Pain and Injuries

This is the time of year when shotgunners are trying to bring back dove, quail and ducks and deer hunters are trying to fill the freezer with venison. Do you have any advice to help them avoid injuries or back pain that might ruin a hunting trip?

“Good posture is the key element of avoiding back pain when shouldering a shotgun or rifle,” he said. “If the hunter is sitting in a duck or deer blind, he or she needs lumbar support. It’s important to stand up and stretch from time to time, even if one is concerned that the game might notice the movement.”

“As always, the best cure for back pain from hunting is prevention,” Dr. Guyer said. “Before getting out in the field and handling a shotgun, it’s important to build strength in core muscles.”

“I also recommend getting some professional advice about proper shooting form. Before going on that hunting trip, go to the shooting range and ask someone who knows proper form to watch you swing and shoulder the shotgun or rifle and tell you if you’re doing it correctly. Then practice that form in the mirror until the gun is placed correctly on the shoulder every time a shot is taken,” Dr. Guyer said.

With more and more women taking up hunting and competitive shooting, are there gender-specific techniques or injuries females should be aware of?

“Unfortunately, back pain is ‘equal opportunity,’” he laughed. “It is gender neutral!”

If you have questions on how to avoid back injuries when hunting or target shooting, click here to speak with a Texas Back Institute specialist.


Senior couple calculating their monthly finances at home.

These are interesting times for healthcare providers and patients. With a few exceptions, the Affordable Care Act has mandated all U.S. citizens must purchase health insurance. It is estimated this will bring millions of previously uninsured people into the healthcare system and many will be confused about their insurance coverage.

While having access to health insurance will enable those with chronic conditions such as back pain to receive medical attention, these newly-insured patients face the challenge of making sense of insurance recommendations which are tied to payments. Understanding these complex insurance coverage criteria requires the patient become more engaged in his/her healthcare. Some feel this will lead to better outcomes.

According to the National Patient Safety Foundation, studies show that more-engaged patients have lower costs and better health outcomes. Unfortunately, the non-profit organization notes the vast majority of Americans “remain relatively uninformed and passive recipients of healthcare services and thus lack the confidence and skills need to fully engage in their health care.”

Diagnostic testing is critical

One of the primary areas where patients are not engaged involves diagnostic testing. Some medical practitioners have noted health insurance companies suggest lower-cost tests or treatment which might impact the patient’s health. We asked Texas Back Institute surgeon, Dr. Jack Zigler if this has been his experience.

Dr. Jack Zigler

“Over the past 5 years, we have seen insurance companies take more control over authorization for diagnostic testing as well as for treatments,” Dr. Zigler notes. “Often they will claim to rely on ‘guidelines’ which are not endorsed by any medical society, but are clearly written from a payer’s (insurance company) perspective.

He continued, “They will use these guidelines to deny tests that doctors recommend, placing both doctor and patient at risk. They have also adopted the tactic of unilaterally considering FDA-approved treatments as ‘experimental and investigational’ and denying authorization for them.”


Someone who is new to insurance might be tempted to assume the companies are patient focused. So, are these insurance recommendations based on costs or medical considerations?

“They are always based on COSTS,” he noted. “They are always biased towards sparing the insurance company from paying for tests or services.”

Have you ever had a patient who was adversely impacted by an insurance company recommendation? 

“Our patients are frequently denied testing such as MRI’sEMG’sdiagnostic nerve blocks and surgical procedures such asartificial disc replacement and coflex which are considered standard of care,” Dr. Zigler said. “We have had patients become reliant on narcotic pain relief, lose their jobs and lose their families due to insurance company denials for needed care.

“We have had patients forced to choose a poorer surgical alternative (e.g. Fusion) because the preferable recommended procedure (e.g. disc replacement) was denied,” he concluded.

What should a patient do when they are given a recommendation and they feel it might not be appropriate to their condition? 

“If they have the time (several months) they should follow the appeals process in their insurance contract,” he noted. “They should call the insurance company daily to complain. They should contact their congressperson and ultimately they should contact an attorney.”

What tests are crucial to spine and back pain treatments? 

“Good imaging such as MRI scans, CT myelograms are often crucial,” he noted. “They are either denied, or are referred by the insurance company to low cost providers who supply the doctor with a sub-optimal, often unusable product. Other tests such as diagnostic injectionsdiscograms, EMG’s are frequently needed but are often denied by insurance companies.”

 Do the physicians at Texas Back Institute encourage patients to ask questions about their treatments?

“Patients at TBI are absolutely encouraged to question their care, ask about alternatives, and get involved in their treatment program,” Dr.Zigler noted. “We also encourage our patients to take an active role in questioning decisions made by their insurance company that are clearly not in their best interests.”

If you have back pain caused by injury or wear and tear, you can be assured Texas Back Institute will use the latest equipment and expertise to properly diagnose and treat your pain. If you have questions about your insurance and our treatment, please click here and one of our insurance specialists will respond immediately.



In spite of the amazing advances in modern medicine, scientists have yet to determine the cause of scoliosis. This may surprise laymen because, according to the National Institute of Health, “scoliosis is estimated to affect 4.5% of the general population. In a nation of approximately 273 million people, this means that over 12 million cases of scoliosis exist, and almost 500 more are diagnosed each day – about 173,000 every year.”

The disease has been referenced in medical literature for hundreds of years and has even been alluded to in a Shakespearean play – Richard III. However, when the Bard wrote the description of the king as “that foule hunch-backt toade” he had no idea he was misdiagnosing Richard. New 3D visualization created by researchers and multimedia experts reveals that his scoliosis was the cause of his poor posture. More on this later.

The spine specialists at Texas Back Institute treat many scoliosis patients each year and we asked Doctors Raj Arakal andIsador Lieberman to explain this perplexing and sometimes debilitating spinal disease.

What is Scoliosis?

Arakal w Patient

“Scoliosis is a side to side curve deformity of the spine that is greater than ten degrees,” Noted Dr. Arakal. “Patients can develop misalignment of their spine which can tilt them side-to-side or pitch them forward.”

“Often the mild curvatures are tolerated well, but sometimes the curves continue to worsen and pose risks of significant deformity,” Dr. Arakal said.

“This condition can also cause a loss of height, restriction of rib cage and breathing,” noted Dr. Lieberman. “Compression of the internal organs such as the intestines, lungs and heart, mechanical back pain, muscular back pain, nerve irritation, spinal cord compression, unappealing physical appearance with rib hump, prominent hip, asymmetric shoulders are also possible.”

What Causes Scoliosis?Lieberman in clinic

This is still pretty much a mystery. Scoliosis often occurs during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown.

“The cause is multifactorial,” notes Dr. Lieberman. Genetic predisposition, mechanical vulnerability, neurological contribution and asymmetric growth issues playing roles.”

“Trauma might play a role,”notes Dr. Arakal. “And it may be related to physiology of the discs.”

Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse. In many cases, no treatment is necessary. Some children will need to wear a brace to stop the curve from worsening. Others may need surgery to keep the scoliosis from worsening and to straighten severe cases of scoliosis.

Did King Richard III Suffer From Scoliosis?


  • According to research published in the scientific journal The Lancet, King Richard’s poor posture and (and perhaps his) unpleasant demeanor seem to be the result of scoliosis.”We wanted to know if Shakespeare’s description was accurate, or an exaggeration to help legitimize the Tudor monarchs on the throne at the time,” study author Piers Mitchell, an anthropologist at the University of Cambridge said “Based on the study of his bones, Richard III would be better described as crook-backed than hunch-backed.
  • In a CBS News report aired in May 2014, it was noted the royal skeleton was discovered under a parking lot in Leicester, England and DNA tests confirmed its identity five months later. In order to figure out the extent of the king’s scoliosis, the researchers created physical and computer-generated models of Richard III’s spine by performing CT scans and then using 3D prints of the bones based on the CT image data.

“The 3D visualization shows that Richard’s spine was curved to the right and it was twisted to a degree, which gave it a “spiral” shape. The researchers also estimated that the king’s Cobb angle — a measure used to determine the extent of spinal deformities — was between 65 and 85 degrees — a curvature that would be considered significant these days. However, he also had a well-balanced curve, which means that his head and neck were straight and not angled to the side.”

“Richard did have a marked  spinal deformity due to scoliosis,” Mitchell said. “However, there was no evidence from his skeleton for his having a withered arm or a limp, as portrayed in Shakespeare’s play.”

Richard’s scoliosis likely started to develop in the last few years of adolescent growth, after he turned 10, the researchers wrote in the study. The monarch’s right shoulder was likely positioned higher than the left one, and his torso was probably relatively short compared with his arms and legs.

The report also noted previous research has already shown that the king would have been about 5 feet 8 inches tall without his scoliosis. But the new study suggests that, because of his spinal condition, he may have appeared shorter than he really was. “This may have made him appear less imposing as a ruler,” Mitchell said.

How Can Scoliosis be Treated?

Texas Back Institute is internationally recognized for effective treatment of scoliosis. “Patients diagnosed with this disease have several options for treatment,” noted Dr. Lieberman. “It’s important to maintain bone health and maintain physical fitness through exercise such as Pilates. We prescribe bracing for those who are in their growth spurt with certain types of progressive curves, medications for those degenerative curves with mechanical or neurological symptoms and as a last resort, surgery for those progressive curves in kids and for the progressive curves with debilitating pain and or neurological issues in adults,” he said.

If you have been diagnosed with scoliosis or have concerns about the possibility of having this disease, contact us for an appointment.


It’s a dreary fall day in Fort Worth. On the heels of a huge storm, Texas Health Harris Methodist Hospital is struggling with leaks. You know the type – the ones that only show up after a major rain and are totally elusive. In fact, some seem completely impossible to repair. It’s like trying to solve an irresolvable case. Fortunately, there are those commercial roofers who like to tackle the impossible, just like Sherlock Holmes has done for years. Through any one of the famous books and various movies and television shows, including the most recent Elementary, you can find Sherlock taking on those tough to solve cases, and using unusual methods of deduction, solving them in grand style.

Much like the famous Watson, with her own methods of deduction and skill, Dalila Vallejo-Newhard, KPOST Company business development representative, shows up at Texas Health Harris Methodist on this dreary day. She understands the challenge that hospitals face after a major storm, and knows that with the right team of savvy professionals, she can ensure the hospital will be leak-free in no time. Desperate for assistance with a leak in the OR, THR Harris Methodist building maintenance supervisor Kobe Owens turned to Dalila for help. And KPOST answered.

“While we recognize we were there at just the right time, our ability to quickly respond to their needs and get a team on-site within a few hours really helped put the hospital back on track after that big storm,” said Dalila. “Our service team is great at finding and repairing leaks. We have a different process from many other commercial roofing companies, so we are able to tackle those seemingly difficult leaks and get them repaired.”

The Problem with Leaks

Tracking down a leak is a specialized skill. It is a combination of art and science, and takes experience. KPOST Company’s service department has the skill and ability to chase down even the most problematic leak. But why is finding and repairing leaks so complicated?

Water can travel vast distances before making an appearance in your building. The entry-point may not be close to where the leak actually shows up. Not only that, but weather events such as snow, ice followed by a drought can fortify a leak by shifting the building creating additional cracks and crevices for water to enter the building.

To truly become a world-class service technician, you have to understand how all the elements have impacted the building, and figure out how to find the exact entry and exit points for the water. Only then can you put a stop to the leak. It takes quite a bit of detective work, and some leaks are more difficult to chase down that others. “Our service technicians have an average of 10 years of experience tracking down leaks” said Tracey Donels, KPost Services Manager.

The Big, Bad, Tough Leak

Unfortunately there are “chronic” leaks that can appear and create havoc, particularly in environments such as hospitals where leaks are particularly devastating. You don’t want to have a leak in any type of building, but those who will lose product, productivity, and patients are particularly vulnerable. Take the case of the 5 year leak.

THR Harris Methodist had tried diligently over five years to have particularly frustrating leak repaired. No one could find the root cause. Enter the “Sherlock Holmes” of commercial roofing repair – the KPOST Company service department. Using the KPOST methodology, the team was able to find the leak and repair it, solving the case once and for all!

Kobe Owens of Texas Health had this to say “Your team has been very easy to work with. They do a great job overall and as a bonus have also done a good job with keeping the roof safe and clean during their service. We look forward to having them out again this week to repair additional leaks.”

Keeping It Clean

Hospitals & manufacturing facilities have specialized needs and are highly regulated. Between the ACA, OSHA and other governmental regulations, it is necessary to take extreme precautions when working in these buildings. When selecting a commercial roofing company to service these specialized needs, it is important to consider the following:

  • Following the Rules – do they understand the regulatory pressures of your environment and are able to accommodate them? For example if you need the team to work in hazmat suits do they follow that request?
  • Experience with Healthcare Facilities – does the commercial roofing company have solid, reputable experience in working with a living breathing facility? Find out through testimonials and references.
  • Good Recordkeeping – can you find out at any time when they last worked on your facility, what they did, and what it cost? Ensuring that the commercial roofing company has the ability to provide you with these records online that gives you the background you need, and the peace of mind that they are tracking the work performed.


“Anyone can say they repair leaks, but it takes a savvy commercial roofing partner to understand all the nuances and needs of the healthcare & manufacturing community,” said Steve Little, president of KPOST Company. “Find a commercial roofer with experience in complex installations, proven successes in finding and repairing leaks and a solid online reporting system to improve the customer experience. This is what to expect and will ensure you get the best service. Otherwise, you may find yourself in the unenviable position of paying to repair the same leak over and over.”

You can find more tips and information in the KPOST Company white paper If Farmer’s Predict a Rainy Season, Can You Keep Water Out of Your Building?“ Download your free copy and learn more about extending proper roof inspections as well as great tips for keeping water out of your building. Download now!


Proving they are not afraid of a little ice, cold water being unceremoniously dumped on them, several physicians and friends of Texas Back Institute took the ice bucket challenge bright and early this morning. In doing so, they joined millions of others who are raising awareness about ALS (Amyotrophic Lateral Sclerosis).

This unusual campaign started innocently enough. Former Boston College baseball player, Pete Frates, created the challenge with his family in an effort to spread awareness of ALS, a disease that he has lived with since 2012. The challenge consists of people dropping buckets of ice water over themselves, recording it, sharing the experience to social media, and then nominating others to do the same. Participants are also encouraged to make a donation to ALS research or to the charity of their choice.

ALS Can Mimic Back Injuries and Diseases

The Texas Back Institute has a special reason for participating in this show of solidarity with sufferers of ALS. Because of its symptoms, such as the inability to grasp objects and the loss of some muscle use, ALS can mimic some spine conditions. In most cases, ALS is fatal, whereas most spine injuries can be treated with therapy or surgery.

Plus, many of the Texas Back Institute physicians have had friends or loved ones who have suffered from the disease. For example, Greg Knittel, a favorite high school teacher of Dr. Rey Bosita contracted ALS and passed away and to this day Dr. Bosita still considers him to be one of the most influential people in his life. To hear his thoughts on ALS, watch the video below.

Let the Dunking Begin!

Without any further ado, let’s get to the main event. Shall we? With this video, let it be known that the physicians and staff of Texas Back Institute support struggle of those fighting ALS and urge you to contribute to finding a cure for this disease.


Photo by Phillip Slaughter

The 101st annual Tour de France is nearing what the French cycling fans might call its denouement. Cycling biggest event started on July 5th  and continues through July 27th  covering 3,663 kilometers. It’s been a tough ride for many of these athletes.

According to news reports, through its first fifteen stages, the Tour has seen the twenty-seven riders drop out due to injuries, including the returning champion, Chris Froome, top contender Alberto Contador and first-tier sprinter Mark Cavendish. American hopeful, Andrew Talansky, hindered by back pain from crashes accumulated early in the race, was also forced out of the race.

With these riders out, the favorites to be standing on the platform in Paris are Vincenzo Nibali of Italy and Alejandro Valverde of Spain. American Tejay van Garderen is also a long shot to win. At the time of this writing, the Washington native was in fifth-place overall, but is less than a minute out of podium placement, a gap that can be eliminated on the grueling Alps and Pyrenees mountains.

With this number of injuries, one wonders about the physical challenges of this sport. We sought some insights from spine surgeon and avid cyclist Dr. Richard Guyer of Texas Back Institute.

How do They Do It?

Spine Surgery in Dallas Texas, Back Surgery in Dallas Texas,

“These riders are  in great shape,” Dr. Guyer said. “They are world-class athletes. They ride at amazing speeds for four or five hours every day of the competition,” he noted.

This begs the question, even as superior athletes, how is it possible for these competitors to remain hunched over their handlebars for more than 100 miles a day?

“They use several tactics to relax their backs,” he said. “The tall riders raise their seats. Most will also hold on the top of the handlebar. This gives their back a break from the lumbar strain,” he said.

“We always advise our patients who have had back surgery or who are experiencing back pain to get up and move around,” Dr. Guyer noted. “Of course, the guys who make the cut for the Tour de France, don’t have any back problems,” he laughed.

“One of the biggest causes for back injuries in a race like this is the crashes that inevitably occur,” he said. “When a cyclists is traveling at 30 or 40 miles per hour, in the middle of a pack of other riders, there’s always the possibility of crashes. This can cause muscle strains or even fractures of the vertebrae,” he noted.

What About the Rest of Us?

Spine Surgery in Dallas Texas, Back Surgery in Dallas Texas,

While following the Tour de France, many casual cyclists renew their interest in the sport and many start riding again. What are the most important things an amateur rider can do to protect his/her back from injury from riding?

“The most important thing is to change the position of the body,” said Dr. Guyer. “If you have back pain, put the handle bars a little higher and lower the seat so that the posture is not as extreme. Plus, if the rider is flexed down too far, they will have to hyper-extend their neck and this will cause pain.

“Building a strong core, with abdominals and back muscle strength, will also help the casual rider avoid pain,” he said. “It’s also important to stretch one’s back muscles before taking off for a long ride.”

What Type of Bike Design is Best for Your Back 

“Racing bikes, with the small tires and curved handlebars, put the most strain on the back,” Dr. Guyer notes. “However, they travel fast and that’s why serious cyclists like them.”

Hybrid bikestrail bikes, with horizontal handlebars and old fashion ‘cruiser’ bikes are easier on the back,” he said.  “If you have a bad back, the more upright the bike, the better.”

“Overall, cycling is great aerobic exercise,” he said. “It doesn’t help with building bone strength, however. “Walking several miles every day is the best exercise for bone maintenance.”

If you’ve started biking and have developed back pain, or if you’re wondering if your back is strong enough to start this exercise, give us a call and set an appointment to talk with the back specialists at Texas Back Institute.


According to a recent story in the Wall Street Journal, the most common form of spinal cord problem of Americans over 55 isspinal cord compression. Since this group is a part of the “Baby Boomers,” largest demographic group in U.S. history, this problem is affecting many people and perhaps you are feeling its impact too.

The medical term for spinal cord suppression is cervical spondolytic myelopathy, or CSM. The WSJ notes, “More aging baby boomers are experiencing neck stiffness, arm pain, numbness and weakness in the hands and legs—all signs of degenerative changes in the upper spine that are usually the result of everyday wear and tear. Strenuous activity or sports can exacerbate the damage.”

“The changes over time can lead to a narrowing of the spinal canal and put pressure on the spinal cord. Coupled with repetitive motion, the compression can injure the cord, which in turn can inhibit movement of the hands and impair walking, and may even lead to paralysis.”

The spine specialists at Texas Back Institute have seen numerous cases of this condition and Dr. Theodore Belanger is well aware of the challenges it presents. We asked him to give us some background on CSM.

What Causes CSM and Spinal Cord Compression?

Spine Surgery in Dallas Texas, Back Surgery in Dallas Texas,

“CSM refers to impingement of the spinal cord in the neck caused by degenerative arthritis,” Dr. Belanger noted. “There are many other things that can compress a person’s spinal cord, such as tumors, trauma, herniated discs, and other conditions, including degenerative arthritis, to which this article is referring.”

“Degenerative arthritis in the neck, and elsewhere in the body, is strongly associated with genetics and aging,” he said. “It is not a single disease that comes in a single form, and therefore there is not a single best treatment that applies to all patients. It also affects men and women equally.”

“In mild forms of the disease, your doctor may recommend simple observation. In severe cases, aggressive surgery may be necessary.” Dr. Belanger noted.

Why are Baby Boomers More Likely to be Affected?

Spine Surgery in Dallas Texas, Back Surgery in Dallas Texas,

“Because the underlying problem is degenerative arthritis, it affects older people,” he noted. “There are increasingly more people seeking healthcare in general in older age groups as a result of the “Baby Boom”. As the population ages, healthcare providers will see more people with conditions of the elderly, like arthritis and CSM.”

Current research noted in this article suggests the number of CSM surgeries has nearly doubled over the past decade to about 200,000 procedures a year, resulting in $4 billion a year in hospital charges alone. Past studies indicate two thirds of CSM patients improve with surgery, while 15-30 percent of the cases are not successful. Complication rates can be as high as 17 percent.

What are the Symptoms of Spinal Cord Suppression?

“Patients with spinal cord compression can present with different degrees of symptoms and findings,” he notes. “Very mild cases may have vague tingling in the arms or hands, while severe cases on the other end of the spectrum may be essentially quadriplegic (paralyzed in their arms and legs).

“The most common patient symptoms include pain, numbness and/or weakness in the arm(s), difficulty walking due to fatigue and feeling off balance, and electric shock sensations down the back or arms with extreme neck movements. Severe symptoms are generally worked up with imaging of the neck, such as by an MRI. If CSM is confirmed, referral to a spine surgeon is appropriate,” Dr. Belanger said.

What can a Patient Expect with Spinal Cord Suppression Surgery?

“The details depend heavily on the health of the patient, the extent and severity of their CSM, and exactly which procedure is necessary, so it is difficult to generalize,” Dr. Belanger said. “CSM presents with a whole spectrum of severity, and even surgical treatment cannot undo all of the damage done by the disease, especially in more severe cases. I would encourage patients to have a frank discussion with their surgeon about reasonable expectations if surgery is being contemplated.”

Because of the pervasiveness of this condition, there is a three-year study being conducted at 10 large U.S. medical centers. It will compare three surgical techniques and create the national spine outcomes registry to help doctors and patients determine which treatment is best for the individual’s condition and situation.

“There are several surgical options available,” Dr. Belanger notes. “This study is attempting to sort out if there are differences in the outcomes for patients treated with one surgical plan versus another.”

If you have any of these symptoms for spinal cord suppression, or are concerned about other back pain issues, contact us for a consultation.


A Problem more common than you might think

By Dr. Michael Hisey

After watching Texas Rangers first baseman Prince Fielder, and pitcher Matt Harrison both end their seasons because of spinal issues, sports fans again saw another top player go down to a back injury - Neymar Jr from host Brazil. It happened in the World Cup quarterfinal in Fortazela  with the entire world watching.

Neymar Jr had helped his side all but secure victory over Colombia when he was struck from behind by a rash challenge from Colombia's Juan Zuniga. After the Impact, Neymar was in obvious discomfort and was stretchered off of the field for evaluation.


As a spine surgeon at Texas Back Institute, several questions occurred to me. More on these later.

The news that followed was quite alarming. The 22 year old Neymar Jr (short for Neymar da Silva Santos Júnior) had reportedly suffered a fracture to his third lumbar vertebra, ending his World Cup and making host country Brazil's quest for a 6th championship that touch more difficult.

There are Many Questions

Early reports were that the player  would miss 4-6 weeks to allow healing of his fracture.  Images of his radiographs (a CT scan reconstruction) have been widely circulated and described as a “clean break”.  But is that really the case?

This image is one slice of what would typically be a several hundred slice study, so any diagnosis based on a single slice is quite limited.  It is not even clear that this is truly an image of Neymar’s back or that the level is L3 – in fact, it appears lower.

But taking all of that at face value, what does the image tell us?  First, there is a break in the bone at an area called the “pars interarticularis”.  But this break does not have the x-ray characteristics of a new injury.  There is healed bone on the surfaces of the fracture.

These images are showing a problem called “spondylolysis". If this really is his only injury, his prognosis for recovery is very different than if he truly had an acute fracture.

What is Spondylolysis and How is it Treated?

Anatomically, spondylolysis is a defect in the ring portion of the vertebra, at what is known as the pars interarticularis.  Each vertebra has joints connecting to the vertebra above and below.  These defects occur between these joints (hence the name “interarticularis”).

There are several theories about just what causes these defects, but common elements to the theories is repetitive stress to this portion of the bone.  The stress may be due to loading in extension – similar to what football linemen experience when they are blocking or impacts gymnasts bear when landing.  This stress is amplified by the presence of the joint above acting like a fulcrum at the weak area of the bone.

If all of this happens in the teenage years, when this portion of the bone is trying to solidify, then a stress fracture can develop.  This can happen with or without symptoms of back pain. This problem is quite common and is a leading cause of back pain in teen athletes.

If caught early enough, spondylolysis can be successfully treated with activity modification.  Often, though, these defects don’t cause symptoms or the symptoms resolve without the bone fully healing, leaving a “pars defect”.  This is such a common problem that most of us probably know several people with it even if they don’t know about it.

What About Neymar?

Neymar on field

This defect does, however, leave a “weakness” in the back.  It might be vulnerable to injury from an impact which might not cause problems if the spondylolysis were not present.  Which brings us back to Neymar.

If these pictures are to be believed, Neymar had a structural defect in his back that was aggravated by a blow to the back in the quarterfinals.  In this case, it is not necessary to wait for the bone to heal to return him to play.  In fact, it is very unlikely for Neymar’s bone to heal, but bone healing is not necessary to return him to play.

It is very likely that, if a CT scan were taken the day before his injury, the “fracture” would look the same.  If I were his physician, the goals I would set for Neymar’s treatment would be to rehab him to the point that he is pain free.  This may be able to be accomplished much more quickly than he could heal bone.  A few of the pars defects that become aggravated by an injury could possibly not recover and eventually require surgery, but that is a very small percentage.

There are literally thousands of athletes performing at a very high level with spondylolysis or pars defects or pars interarticularis stress fractures..  There are even more recreational athletes with the same issue. So, if the images on the web are really Neymar Jr, don’t be surprised to see him back for the final in Rio, should Brazil make past Germany today in Belo Horizonte.

About the author of this post:

Dr. Michael Hisey is an orthopedic spine surgeon at Texas Back Institute. He is a member of the American Board of Orthopedic Surgery and the American Board of Spine Surgery. He is the official spine specialist of professional soccer team - FC Dallas - and is one of the world's biggest sports fans! Click here to schedule an appointment with Dr. Hisey.


“I had lower back pain for years and finally one day I decided to do something about it,” said Celeste Reynolds. “I waited for two years after my surgery to share this information because I really wanted to make sure what I am saying is the truth about the surgeons and staff at Texas Back Institute.”

Thus begins a note from Celeste who came to Texas Back Institute because she couldn’t stand the pain any longer. Her story should be of great interest to anyone who is experiencing chronic back pain.

“As always, surgery is the last option we pursue”

Texas Back Institute surgeon, Dr. Jessica Shellock examined Celeste and she still remembers how much pain this project manager was suffering.


“Her diagnosis was multilevel degenerative disc disease, Dr. Shellock noted. “It’s not actually arthritis per se, since the discs are not joints.

“It is more an acceleration of the normal aging process of the discs that we will all experience over time – some people are more genetically predisposed to accelerated changes and earlier and/or more severe symptoms. It really is more hereditary than anything else,” she said.

“As always, surgery is the last option we pursue,” she said, “But after exhausting every other treatment regimen, on May 16, 2012, we performed the surgery.

“We try our best to do minimal fusions”

With the help of one of the founders of Texas Back Institute, Dr. Richard Guyer, Dr. Shellock performed both a fusion and artificial disc replacement procedure in hopes of eliminating the constant pain Celeste was experiencing. We asked her if this type of surgery is unusual.

“Not really unusual,” she said. “It’s difficult to get insurance carriers to approve these types of constructs (we call it a “hybrid” construct since it involves both fusion and disc replacement), so fusion alone is much more common overall. We completed one artificial disc replacement at L3/L4 and two fusions at L4/L5 and L5/S1.”

“In the setting of a multilevel problem as this, we try our best to do minimal fusion(s) if we can so that we give the patient a better chance of decreased need for future surgery. Since insurance carriers won’t approve multilevel disc replacement and this is often cost-prohibitive for patients to self-pay, we essentially do a compromise between the two options,” she said.

“I’m here to tell you that the best thing I have ever done for myself is getting my back fixed at Texas Back Institute!”

“I can’t explain how freeing this is,” Celeste said. “If I think about it too much, I’d start to cry.”

“Within six months, I was back to walking and moving with no pain,” she proudly said. “I credit the skillful hands of these two doctors for my quick recovery! Dr. Shellock and Guyer are so competent, knowledgeable and skillful and I would recommend them to anyone.”

“I went to physical therapy at Texas Back Institute,” she said. “And I followed the recommendations of the knowledgeable technicians there. The day I was released from the hospital I received one directive – to get up every half hour and walk for five minutes.”

Her lack of back pain has allowed Celeste to travel the world. Since her surgery, she’s created a spreadsheet of all the places she’s gone and it reads like an airport departure screen! Among other cities, she’s traveled to London, Barcelona, San Diego, Honolulu, Washington D.C., Atlanta, Denver and of course walked around her beloved State Fair of Texas!

“Freedom from pain is indescribable”

“Dr. Shellock is a wonderful human being,” Celeste said. “And totally amazing in her work.”

“I’m flattered and humbled by her words,” said Dr. Shellock. “I am so happy that she has done well and is back to all the activities that she hoped to be doing."

“I think that she represents a combination of the correct surgery for the appropriate indications, a great OR team, and a motivated patient with a wonderful attitude for recovery. It really takes all of these things for this type of success, and when they are present together we can see outcomes like this that can truly give someone back the quality of their life. This is what makes my job enjoyable!”

“Freedom from pain is indescribable,” summed up Celeste. “But it’s reachable through the great doctors and physical therapists at Texas Back Institute. I thank the good Lord I found them!”



(Photo by Keith Allison found here on

Why his decision might impact you

Texas Rangers first baseman Prince Fielder, who came to the club in a much discussed trade for longtime Ranger and All-Star Ian Kinsler in the offseason, is done for the year. According to and other sports media, he had cervical fusion of the C5/6 discs in his neck on May 27th in Dallas. As the club indicated last week, he's expected to miss the rest of the 2014 season.

While this turn of events is bad news for the Rangers, already reeling from the loss or several other players, it has also spawned a new round of controversy. This time the discussion is about whether the spine fusion procedure was the correct call for the player’s short-term and long-term health and career. Should Fielder have chosen a more high-tech, albeit newer procedure – artificial disc replacement?

Since Texas Back Institute has pioneered many spine surgery techniques including artificial disc replacement, we asked one of its surgical experts, Dr. Michael Hisey, to weigh in on the Fielder’s decision and prognosis.

The Iron Man Goes Down

The season-ending surgical procedure came about when the 30-year old first baseman was unable to play due to a herniated disc in his neck. This injury included weakness in his left arm which is not only frightening but a distinct disadvantage when one’s occupation involves swinging a bat while trying to hit a baseball which is traveling 90 miles per hour!

Up until this injury, Fielder was considered to be one of baseball’s “iron men.” This is the first time he's been on the “Disabled List” in his entire career. According to Major League Baseball, the first baseman ended his streak of 547 consecutive games, the longest active streak in the majors. He had played in at least 157 games in each of his eight seasons with Milwaukee and Detroit prior to 2014.


Advantages and Disadvantages

When a professional athlete opts to have surgery, it is not a casual decision. It could mean an end to his livelihood. We asked Dr. Hisey what the short-term and long-term ramifications of Fielder’s spinal fusion procedure were.

Michael S. Hisey, M.D.

“In the short term, he will have limited ability to participate in sports and athletics,” said Dr. Hisey. “It will take 3 to 6 months to get the bone healed and even though he will be able to walk, he won’t be swinging a bat or sliding into second base. Long-term, his ability to play at the professional level will depend on lots of factors.”

Fielder, his physician and the Texas Rangers decided to pursue the spine fusion option for his injury. What are the advantages and disadvantages of this choice?

“Fusion surgery has been used for 20 or 30 years and it is a reliable way to restore normal function,” noted Dr. Hisey. “His arm weakness should go away because the pressure will be taken off the nerve. This procedure has been performed with other professional athletes such as Peyton Manning and they were able to get back to action.”

In looking at the disadvantages of fusing vertebra, Hisey said, “This procedure stops the motion in that area by stiffening the area placing more stress on the discs above and below. This can cause increased wear and tear and degeneration of the discs over time.” Research shows fusion can lead to as much as twenty-five percent degeneration of the adjacent discs over 10 years,” he said.

“Another disadvantage is long recovery required for fusion surgery,” Hisey noted.

What about artificial disc replacement? What are the pros and cons of this procedure?

Artificial Disc

“Motion is preserved with artificial disc replacement,” Dr. Hisey notes. “The pressure on the nerve is relieved, so arm strength can be regained and there is not loss of motion and therefore less potential for degeneration of the discs above and below the new disc.”

“The primary advantage of artificial disc replacement is the dramatic difference in recovery time versus the fusion procedure,” Dr. Hisey said. “Had Fielder chosen an artificial disc, he could have been in rehab in 6 weeks and could arguably be playing competitively in 3 months. This means he could have had a chance of being back in the lineup by September,” Hisey concluded.

“Because this is a relatively new procedure, without as much clinical history, some might feel this is a disadvantage,” Hisey said.

Not Everyone is a Candidate

If the two procedures are comparable in terms of successful outcomes and the recovery time is less, why wouldn’t everyone with this type of injury choose the artificial disc replacement route?

“Not everyone is a candidate,” noted Hisey. “Fielder’s doctor may have found that his physical situation is not appropriate for this procedure.”

“A typical soft disc injury or “herniation” is a good candidate for an artificial disc replacement,” said Dr. Hisey. “However, if there is instability at the injured disc level, or if the procedure will require taking too much bone, fusion may be the only option.”

“Other medical conditions can preclude someone from choosing artificial disc replacement,” he said. “Someone with osteoporosis, infection or spinal cord compression is not a good candidate for this newer procedure.”

Most of us are not professional athletes whose career depends on being in superior condition. What about normal men and women who have had injuries or disease which damage discs. Which is the better choice – fusion or artificial disc replacement?

“If one meets the medical criteria noted above, there’s no question which procedure is superior,” noted Dr. Hisey. “Artificial disc replacement is safer, it preserves motion thereby avoiding degeneration of the discs later, there are fewer complications, there is better pain relief and the recovery time is quicker.”

If you are interested in getting more information on artificial disc replacement or have any other questions regarding treatments for back or neck pain, contact us at Texas Back Institute.