For anyone reading the April 16, 2014 edition of The Wall Street Journal and contemplating implant surgery for a spinal-cord stimulator, the news was frightening. The headline set the stage: “When Spine Implants Cause Paralysis, Who is to Blame?”

According the newspaper’s analysis of adverse-event reports submitted to the U.S. Food and Drug Administration and a review of malpractice lawsuits, more than 100 patients have experienced partial or permanent paralysis in recent years after having spinal-cord stimulators inserted in their backs. The article went on to note, “In many cases, the injuries occurred after patients’ spinal cords were punctured or compressed by the stimulator electrodes, which are implanted in a narrow cavity of the spine called the epidural space.

Since this procedure was pioneered and has been performed by the skilled surgeons at Texas Back Institute more than 10,000 times since its introduction, it’s logical to ask two of these spine specialists about this story. Dr. Michael Hisey and Dr. Ralph Rashbaum, in separate interviews, both agreed the facts presented by the Journal about this procedure are not wrong. They also agree with the conclusions drawn by the experts interviewed by the newspaper – the problem is not with the spine stimulator device.

“It’s ‘pilot error,’” said Dr. Rashbaum. “The article rightfully pointed to the real problem of this procedure and that’s a lack of training for some of the physicians who are performing the surgery.” More on this later.

 How the Spine Stimulator Relieves Chronic Pain

The spine stimulator devices are made by several companies, including Medtronic, Inc., St. Jude Medical, Inc. and Boston Scientific Corp. Each uses electrical signals, which emanate from the implanted device and is then transmitted through electrodes connected to the spinal cord to block the pain signal before it is received by the Thalamus portion of the brain.

When properly placed in the back, these stimulators have an overwhelmingly high success rate. As one can imagine, for someone who has suffered chronic back pain for decades, this device is a god-send.

“I was one of the early adaptors of this technology,” said Dr. Rashbaum. “I’ve been performing this procedure for more than 37 years, more than 5,000 times and I’ve worked with all of the medical device companies who manufacture them. I have testified as an expert witness in cases related to these devices and have even invented devices from which I receive royalties from one of the companies – Medtronic, Inc.”

By any metric or criteria, Dr. Rashbaum is one of the internationally-recognized experts on spinal cord stimulators and it’s telling that he has serious concerns about the (lack of) training some physicians receive before performing this surgery.

Training is Inadequate 

“Two days, which is the standard amount of time manufacturers allocate to explaining this procedure, is not nearly enough,” Dr. Rashbaum said. “Our doctors at Texas Back Institute must go through a full year of training, mentoring from other physicians and operate under close supervision before being allowed to perform this procedure. Why? Unforeseen factors arise in surgery and you never want these factors to occur when someone is only just learning the procedure.”

“The real problem we see and that which the Journal rightfully pointed out is a lack of training in the proper implantation of these devices,” said Dr. Hisey. “The devices are sound. However, when you have physicians who have never had surgical training and proper mentoring by more experienced doctors certified to perform this surgery two days of training is not enough. Unfavorable outcomes will occur.”

What Can Go Wrong?

What are the types of physician errors which might cause paralysis in a patient undergoing this type of spine stimulator procedure? Dr. Rashbaum, who after performing more than 5,000 of these procedures has never had a patient failure resulting in paralysis, notes several.

“When implanting the device, an inexperienced surgeon will sometimes put too much pressure on the spinal cord causing a bruise or contusion,” he notes. “If this pressure is severe, it could cause damage to the spinal cord and paralysis.”

“The electrode leads can also be pushed too far in this procedure,” Rashbaum notes. “And this is often difficult to determine, especially if the patient is under anesthesia. My experience has taught me to keep the patient awake through the procedure, monitor their progress electronically and listen to the patient.”

“Another problem which might cause paralysis is an epidural hematoma,” he said.

“Infections can occur even with good technique. However, a good team using appropriate technique can significantly decrease the number of infections.”

“Epidural hematomas (blood collection) are another possible cause of cord injury. These can occur when the epidural veins (the veins around the cord) are torn by the electrode lead. Bleeding in the epidural space causes pressure on the cord and it can be significantly injured.”

“All of these errors are preventable with proper and extensive training,” Dr. Rashbaum concluded.

Training Future Spine Specialists

How does Texas Back Institute prepare its physicians for spine stimulator implant surgery and the other ground-breaking procedures such as artificial disc replacement, SI joint fusion, herniated disc surgery and any number of other specialized procedures? It’s the same way a concert pianist gets to Carnegie Hall. Practice. Practice. Practice!

“Every year we offer fellowships to 2 to 5 physicians who have graduated a residency and want to learn more about the specialized surgery Texas Back Institute is known for,” said Dr. Hisey. “It is extremely rare for a private practice such as ours to offer this year-long training to future doctors who will not necessarily join our practice.”

He continued, “We do this because we believe in the benefits of mentoring young surgeons. After successfully completing our fellowship program, they have participated and observed hundreds of procedures such as the spine stimulator implant surgery. Some of them are asked to join our practice and some go on to other practices. However, they are all better doctors when they leave.”

“For the physicians who join the Texas Back Institute, we require a one-year period of specialized training (Fellowship) in spinal surgery during which they will typically supervised by senior physicians for about 500 to 600 cases before they graduate,” Dr. Hisey said. “After joining TBI, each will have their cases reviewed and will be supervised over the first several months before they operate independently.”

What Questions Should a Patient Ask?

Every doctor hopes to avoid the tragedy of permanent paralysis noted in the “Journal” article and every patient should take some responsibility. What are the questions a person who is considering this spinal stimulator surgery? Dr. Rashbaum offers a few.

“A patient should ask their physician about the number of cases, complication rates and outcomes they have had related to the spine stimulator device,” he said. “In my practice my trial-to-implant ratio is higher than 90 percent. This is due to my extensive screening and evaluation of each client. If a physician performs a large number of trials and his permanent implant rate is low, this could be a red flag. For example, the pain reduction ratio should be at least 50 percent in the trial before the final procedure is attempted.

Let’s face it. Some physicians perform this procedure better than others,” Dr. Rashbaum said. “Just because a pain-management doctor or anesthesiologist goes through two-day training for spine stimulator implants does not mean he or she is qualified for this type of surgery. Errors can occur and the damage to the patient can be permanent.”

Dr. Hisey adds, “A two-day course might be adequate to learn the nuances of a modification of a technique which the surgeon is already proficient in but it does not replace surgical training or practicing a procedure in a supervised setting.”

Dr. Rashbaum reminds us, “We physicians must live by the oath we take – ‘Primum non nocere.’ First do no harm.”

It’s been a long time since Tiger Woods has missed playing a Masters Golf Tournament – back to 1995. However, he won’t be playing in the 2014 edition of one of professional golf’s biggest tournaments due to recent back surgery. Some feel he may never return to the form which enabled him to win his first Masters in 1997.

Since Texas Back Institute has internationally recognized expertise in this type of back surgery procedure, we asked Dr. Jack Zigler and Dr. Scott Blumenthal for their insights into the causes and effects of Tiger Woods’ back ailment and the surgery which will keep him away from the lush fairways of Augusta National. More on this later.

Woods Announces his Condition on the Web

Woods announced his medical status and subsequent absence from the PGA tour on his website (www.tigerwood.com) on April 1, 2014, and this was no April fool’s day joke. He noted he had undergone a successful microdiscectomy for a pinched nerve which had been hurting him for several months. The surgery was performed in Park City, Utah, by neurosurgeon Dr. Charles Rich.

While the procedure was successful, Woods will be unable to play in the Masters Tournament, instead requiring rest and rehabilitation for the next several weeks. It was clear that this decision had been a painful one for the golfer.

According Woods, “After attempting to get ready for the Masters and failing to make the necessary progress, I decided, in consultation with my doctors, to have this procedure done,” Woods said.

“I’d like to express my disappointment to the Augusta National membership, staff, volunteers and patrons that I will not be at the Masters,” Tiger added. “It’s a week that’s very special to me. It also looks like I’ll be forced to miss several upcoming tournaments to focus on my rehabilitation and getting healthy.

“I’d also like to thank the fans for their support and concern. It’s very kind and greatly appreciated. This is frustrating, but it’s something my doctors advised me to do for my immediate and long-term health.”

Medical Analysis from the Experts at Texas Back Institute

The medical procedure which will determine the professional fate of one of golf’s best known players is called a microdiscectomy.

According to Dr. Jack Zigler a spine surgeon at Texas Back Institute, “A microdiscectomy is a surgical procedure to relieve pressure on a nerve root by removing a portion of the intervertebral disc that is pressing against it.  It is done under magnification so that only minimal manipulation of the nerve and minimal removal of healthy covering tissues are required.”

“The procedure is typically used for a herniated lumbar disc,” he said. “The disc, or shock absorber between the vertebral bones, can develop a weak spot or tear in its outer wall, allowing some of the “jelly” in the center to bulge or extrude, putting pressure on one of the nerve roots running down the leg.  This can cause pain, weakness, numbness, and tingling.”

The big question for any Tiger Woods fans concerns his long-term ability to play at the level he has been able to play for almost 20 years. Will this procedure affect the flexibility of that famous Tiger Woods swing?

“The procedure itself does not affect flexibility, Dr. Zigler noted. “However, if the disc has been very damaged by the herniation, it may collapse over time, and that could limit flexibility.”

Professional golf owes much of its popularity, especially among young golfers, to the skills and personality of Tiger Woods. Every tournament organizer, including those at the Masters in Augusta, knows how much excitement Woods adds to an event. For this reason, the length of time he will miss due to rehabilitation is on the minds of many.

According to Dr. Scott Blumenthal, another spine surgeon at Texas Back Institute, “The rehab process begins immediately after surgery with sports specific activities resuming at about 4 to 6 weeks. Tiger’s return to full activities or sports is variable but generally he should be back playing in 2 to 3 months.”

“Because a professional golfer is in better condition, he would typically require less rehabilitation than the average person” Dr. Blumenthal notes.  “Professional golfers have strong cores, which are the key muscle groups that protect the disc against recurrent injury,” he said.

Sports talk show hosts love to speculate on the future prospects of professional athletes – especially Tiger Woods. Can Woods, who is 38 years old, come back from this procedure and perform at the high level we’ve all come to expect?

“Tiger Woods is a superbly conditioned, elite athlete, who is in the best condition possible,” notes Dr. Zigler. “Depending on the health of his disc after the herniation is removed and the annulus (wall of the disc) heals, he may easily be able to return to his pre-injury form and play at that level for many years. However, if he has lost a lot of the nucleus (“jelly), and/or the annulus fails to heal well, he will have problems functioning well.  After a disc herniation, everyone is at a slightly increased risk of recurrent herniation as well as disc space collapse and arthritis,” he said.

The legions of Tiger Woods fans miss seeing him storm his way to the 18^th green at this year’s Masters Golf Tournament. They can only hope that medical technology, combined with his dogged determination to win will have him back at Augusta next year.

Twice each year, “Fashion Week” occurs in the major fashion cities – New York City, London, Milan and Paris. During the month of February, clothing designers show off “what’s hot,” or rather, what will they believe will be hot for the coming fall and winter, by staging elaborate fashion shows and media events.

Each show combines music, elaborate choreography and dozens of svelte models dashing around the stage. Many of these models spend hours on their feet, walking the runways while wearing high-heel shoes. While these shoes look great with the clothes, they can be painful to wear and there is even some concern about their effect on other parts of the body including the spine. Even if you’re not a “fashionista,” if you’re a woman, you probably wear high-heels at some point during the week.

They may be very flattering to one’s legs but do these shoes damage your back? We chatted with Dr. Jessica Shellock, a spine surgeon at Texas Back Institute, to get her perspective on high heels and their effect on spine health. Keep reading to get her stylish medical opinion.

In Fashion, Nothing Exceeds Like Excess

According to the Wall Street Journal, the just completed New York City Fashion Week shows featured diverse collections which have “prescribed a utilitarian yet luxe antidote to the polar vortex.” This included alpine sweaters, puffer coats in leather, fur and embroidery and cozy flat-soled boots. Well-known fashion designers such as Donna Karan, Tory Burch, Michael Kors, Ralph Rucci, Diane von Furstenberg and Marc Jacobs presented their collections and each garnered glowing reviews.

There were many highlights of the NYC Fashion Week shows. These include:

• Designer Stuart Vevers’ fireman’s coat, complete with toggle buttons and constructed of black motorcycle-style leather for Coach.
• Ralph Rucci had one of the more spectacular coats of the week. The Wall Street Journal fashion editor – Christina Binkley – noted it was lined with Barguzin sable with an outer layer of Nappa leather. She opined, “The coat looked as suitable for driving a dogsled as for hurrying down Fifth Avenue.”
• Plaids were big at the show with Tracy Reese and Marc by Marc Jacobs contributing several designs using this garment staple.
• Pants in this year’s show seemed by many to be inspired by actress and icon Katherine Hepburn. They were wide-legged and often long.
• Jackets and tops will have “voluminous sleeves and curvaceous backs” next fall and winter.
• Fur bags will be hot next fall. Designers Tory Burch and Derek Lam all had new variations on this old theme
• It wouldn’t be Fashion Week without the unusual. Designer Rodarte created gown with Star Wars images of Yoda, R2-D2 and Luke Skywalker printed on the skirts! Tres chic!

Can High Heels Ruin Your Back?

Many of those (very) thin models who pranced across the runway during Fashion Week, showing off the latest of haute couture, were balancing their exaggerated gait on a pair of high heel shoes. While the history of high heels is storied – they first came to be used in 9^th Century Paris to keep horseback riders’ feet in the stirrups – most women wear them because they give the illusion of longer, more slender legs.

However, after an entire day at the office or several hours on the fashion runway, many women wonder if this illusion is worth the pain. Plus, some non-medical analysts have suggested that high heels can permanently injure one’s back.

“Wearing high heel shoes does not injure a woman’s back,” noted Texas Back Institute physician Dr. Jessica Shellock.

“However, for people that are already predisposed to back pain, wearing high heels might lead to episodes of increased pain. There’s more of a risk of developing foot problems (i.e. bunions) with longstanding use of high heels than back problems,” she said.

One hears stories of women who have had back surgery being forced give up wearing high heels. Is it advisable to avoid high heels after back surgery?

“I think it’s reasonable to limit or avoid high heel shoes for at least a short period after back surgery, notes Dr. Shellock.

“Wearing high heel shoes causes a woman to hyperextend her back for balance. Depending on the specifics of the surgery, a woman might have restrictions from her surgeon such as avoiding hyperextension. The hyperextension might also increase muscular pain in the area of a surgical incision, so in my practice I try to encourage patients to avoid heels for at least a number of weeks after surgery and stick to shoes that have better cushioning and more ankle support.”

Dr. Shellock continued, “From an even more practical standpoint, I think we can all agree that high heels put us at more risk for a potential ankle injury than comfy flats or sneakers. The last thing I’d want a post-op patient to experience would be a “twinge” of back pain or leg pain that led to a trip or fall and subsequently caused an inadvertent ankle sprain!”

Are there medical conditions related to the back muscles and spine which can result from high heels?

“It’s the fact that we tend to hyperextend the back when we wear high heels so that we can maintain our balance. This puts extra strain on our muscles and can lead to back pain,” notes Dr. Shellock.

“Plus, in patients that have facet-mediated pain or spinal stenosis, for example, extension of the back is what usually exacerbates symptoms. Wearing heels would lead to extension as we discussed and would therefore be likely to aggravate the pain. As with most things in life, moderation is probably the way to go!”

The very stylish Dr. Shellock concludes with some practical advice.

“With that being said, I absolutely love wearing high heel shoes myself. However, I limit my use! If I know I’m going to be on my feet in clinic for 8 hours then I might wear some equally stylish but slightly more comfy wedges or boots and save the killer heels for date night!”

Reality TV stars Honey Boo Boo and her family were in an auto accident last week.  Fortunately, no one in the family featured in cable show “Here Comes Honey Boo Boo” was seriously injured.

News media from around the world have given prominent coverage to the accident, due to the public’s fascination with the family from rural McIntyre, Georgia. According to wire services, young reality star Honey Boo Boo and members of her family were in a car accident on January 6, 2014. The 8-year-old, along with her mother, Mama June, and older sister, Pumpkin, were passengers in the car being driven by the Thompson family patriarch, Sugar Bear.

According to TMZ, “the family was at a red light, waiting to turn left. When the light turned green, Sugar Bear began to make his turn, but a truck, which was allegedly speeding, ran a red light and smashed into the car.”

Honey Boo Boo’s family is not alone in feeling the pain of vehicle accidents. The U.S. Department of Transportation estimates there are over six million vehicular accidents every year in the United States. Worldwide, an estimated 1.2 million people are killed and fifty million injured in car accidents.  Some of these victims find their way to the examining room of back specialist Dr. Craig Callewart of Texas Back Institute. Recently, we chatted with him to get some insights about the physical effects of vehicle accidents. More on this later.

An 8-Year Old Reality Star

Ms. Boo Boo, whose legal name is Alana Thompson, rose to fame after appearing in The Learning Channel’s reality show “Toddlers & Tiaras” which shared the trial and tribulations of young beauty contestants. The sub-plots included members of Thompson family as they found ways to scrape by on Sugar Bear’s meager earnings from his job as a chalk miner.

With the accident behind them, the family of Honey Boo Boo can hopefully get back to show business. The next season of the show begins on January 16, 2014. However, there may be complications from this car crash and we asked back specialist Dr. Craig Callewart to give us some insights about the injuries which might result.

After the Accident

“It’s very possible to walk away from an auto accident and have serious injuries show up later,” Dr. Callewart said.

“After an accident, the body is in shock and adrenaline covers the pain. So, the body of the accident victim will often fail to recognize the pain from injury until later.”

Since so many people are involved in vehicle accidents each year, there’s a great possibility that at some time or another we all will go through post-accident trauma the Thompson family is experiencing. It therefore seems prudent to see a physician – preferably a specialist such as those at Texas Back Institute – after an accident.

As a spine trauma specialist, what are the three things that Dr. Callewart checks on a patient who has been in an accident?

“For someone suffering from a neck injury, I first check for headaches,” he notes. “Having headaches suggest more severity in the injuries which can be caused by whiplash from the accident.”

“We also check for muscle spasms and sprains,” he said. “If these are being experienced by the patient, there is a possibility of more serious injuries.”

“Finally, I look for pain that might that might be shooting from the neck to in between the shoulder blades,” he noted.

Common Injuries from Car Crashes

In his practice, Dr. Callewart deals with many traumatic injuries to the back muscles and spinal column. What are the most common injuries that result from a motor vehicle?

“Muscle strains or ligament strains are statistically the most common injuries we treat after an auto accident,” he noted. “While not as dangerous as fractures to vertebrae, these injuries can be extremely painful and require rehabilitation and medication.

“Disc herniation or rupture in the spinal column, which less frequent, can also occur after a vehicle crash,” he notes. “The impact of the crash can force the discs between the vertebrae to compress and this can cause them to rupture.”

Pain and soreness are common for anyone who has experienced a wreck. Is there anything to be done to ameliorate this pain?

“While driving, don’t sit in bucket seats,” he notes. “The pain will be less if one rides with the hips up higher than the thighs.”

“After a crash, the victim’s neck will likely be sore and this is a good time to learn how to properly use the side and rearview mirrors when backing a car. When these are used properly, there is less likelihood of further neck strain resulting from quick head movement.”

Other ways to avoid this neck strain while backing is to purchase a small, self-adhesive inexpensive round mirror and stick in on the side mirror. This will afford a larger view for the driver. Dr. Callewart also recommends an enlarged rear-view mirror which can give a 160 degree view.

The best way to avoid the pain and injury of an accident is to avoid them altogether by driving safely and buckling one’s seatbelt. However, this is not always possible. As Dr. Callewart notes, “Car crashes simply follow the laws of physics. A heavy vehicle (mass) going at even a moderate speed (velocity) will result in a force or momentum that can cause great destruction.”

Accident behind them, Mama June, Sugar Bear and Honey Boo Boo will all be back for another year on TLC in January. You can bet the producers will find a way to work this crash into the storyline. Stay tuned.