Developing new habits and keeping to resolutions is a matter of persistence, focus, and perseverance. Thinking about making a change is a lot more fun than carrying through with it once resistance sets in. But, with some simple techniques, like using SMART goals and using one key habit to influence all others, we know you’re going to crush 2018’s resolutions. Here’s how.

What are SMART goals, and why are they important for resolutions? 
“Get healthy”: does this sound like a fitness goal you might set? Those two words are responsible for more secondhand fitness equipment than any other words in the dictionary. The problem with this goal is that it isn’t very SMART, and when it comes to healthy fitness resolutions, SMART goals are the only way to go.

SMART is a goal-setting acronym used to structure goals so that they are successful. SMART goals are:

• Specific
• Measurable
• Attainable
• Realistic
• Timely

Let’s look at how you can use this acronym to set yourself up for success for your resolutions this year. Since the most popular resolutions have to do with fitness and losing weight, we’ll be looking at those in particular. But remember, any resolution can be made into a SMART goal: practicing more relaxation techniques, meditating, committing to a new hobby, or encouraging more mindfulness in the new year.

SMART goals are specific
Let’s say your resolution is to lose weight. If you state your goal that simply, even losing six ounces of weight would count as having achieved the goal. Chances are good that you’d like to lose more than that. An example of a specific goal is, “Lose 15 pounds.” The number might change, but the number is specific, not general, and it gives you something to focus on.

The same thing applies if you are trying to increase your level of physical activity. You could say, “I want to exercise more,” a vague goal that allows you to exercise precisely 15 more seconds a day to achieve it, or you can say, “Exercise 30 minutes daily.” In this example, more is defined and specific.

To make your goals more specific, think in terms of:

• Who is involved: Only you? Will you need a trainer or other support?
• What you want to achieve
• Where you will meet your goal: The gym? A hiking trail? Your own neighborhood?
• When: Commit to a timeframe
• Why: What are the benefits of achieving the goal? It helps to write them down

So your final SMART goal statement might be “Join a local bike club and go on their weekly ride while also riding my bike for 30 minutes a day.”

SMART goals are measurable
Fitness resolutions include not only physical health but also mental and emotional health. Maybe you reflected on the past year and have decided that you want to increase your level of happiness over the next year. Setting the goal “be happier” will not be helpful because you have no way of knowing whether or not you are actually happier than before. That goal is not measurable. Because research has shown that a gratitude practice can make you happier, your goal might be to cultivate gratitude to increase your happiness. You could say, “Write five things I am grateful for every night before bed.” You can see whether or not you have written five things nightly and extrapolate your increased level of happiness. With more concrete goals like weight loss, a scale is your measurement. For goals related to nutrition, recording the servings of fruits and vegetables daily and checking against recommended daily allowances is measurable. Thinking like a scientist helps here. Try to set a goal that anyone could measure. Don’t base a goal on whether or not you “feel” different: prove it.

SMART goals are attainable
Maybe we’d all like to look like a movie star and have the body of an Olympian. Maybe we want to cook fresh, healthy meals with the ease of a celebrity chef, or bend and twist our bodies in yogic serenity like the yoga stars on Instagram. While these goals may be possible for some, they are not attainable for all. Every body is different, and every person setting goals needs to accept their own body’s strengths, limitations, and pocketbooks. Movie stars have stylists, Olympians have trainers (and no other job), celebrity chefs have prep cooks (and dishwashers!), and some particularly bendy yogis practice daily for hours. For most of us, being a movie star, Olympian, celebrity chef, or rock star yogi is not an attainable goal.

Attainable goals are goals that are steps to the final destination. They are way points that you can actually achieve on your way to the overall end goal. Your overall goal may be to exercise for an hour daily, but if you are just starting an exercise regimen or you are coming back from an injury, maybe your first goal is to exercise for ten minutes daily, gradually adding time and intensity over a period of six months.
The same goes for diet. An attainable dietary goal might be to eliminate soda completely or to add two servings of fruit and vegetables daily. You might set the goal to have one meatless meal a week. Fitness resolutions dealing with diet often fail because the level of deprivation is so high people feel unable to maintain their willpower.

SMART goals are realistic
There is the simple fact that some goals are not realistic. If you are aiming to lose 200 pounds in five months, that goal is not only very difficult to achieve but it is also very unsafe. If you have not exercised at all and try to set the goal of two hours of daily exercise you risk injury. SMART goals focus on what is realistic for you based on where you are starting and what you can safely and realistically accomplish.

According to an article in Shape magazine, a SMART goal would be to lose eight to ten pounds a month following a strict plan: “Losing one pound of body fat is equivalent to 3,500 calories. To lose two pounds per week, you must drop 1,000 calories per day.”

Eliminating 1,000 calories a day may be difficult for you, but safe weight loss is about two pounds a week. Any other goal endangers your health and can lead to eating disorders.
Setting realistic weight loss goals sets you up for success, just like setting realistic fitness goals. Work and family get in the way of training or exercising for five hours a day. That schedule is not realistic. A realistic exercise goal might be to go on a hike every weekend with your family and walk daily for at least 30 minutes. A daily 30-minute walk is more realistic for most people. A realistic goal is also one that you are both willing and able to work towards. If you are setting a goal based on anything else, chances are good you will struggle to achieve it.

SMART goals are timely
Give yourself a deadline. Fitness resolutions to “get fit” and “eat better” are not worth the screen you read them on. Give yourself daily deadlines, weekly targets, and monthly milestones. This will help you break a larger goal into smaller steps and make it seem less overwhelming. Plus, the calendar doesn’t lie. Setting a time frame keeps you focused and on track.

Setting SMART goals doesn’t mean that you shouldn’t aim high for diet, weight loss, and exercise. Your resolutions should aim for optimal health, both mental and physical. SMART goals help you take steps along the way and keep you focused on your ultimate goals with a higher chance of success.

How working out can actually help you achieve other resolutions
So, you’ve nailed the SMART goals and want to make sure you follow through with your 2018 resolutions. How can you make that happen?

One trick is to focus on exercise, a lynchpin for so many other activities we do. Fortunately, discipline learned in one area of life bleeds into other areas of life. That’s how working out can help you achieve other resolutions. Crushing fitness goals is a wonderful way to help you achieve other resolutions. If you already exercise, tap into this resource to fuel your fire to achieve other goals. And if you don’t exercise, consider setting small exercise goals and using the lessons learned to help you achieve your other resolutions.

Practice perseverance 
How you do one thing is how you do everything.
Learning to stay on the treadmill for the entire 30 minutes you’ve decided to walk or run, even when you want to get off after 15 minutes, is an exercise in persistence. Hitting the gym on a Tuesday night when you’re tired is a lesson in dedication. These skills are learned, like any other skill. And once you learn them, you can do anything you put your mind to.

Learning the skills of perseverance and dedication through exercise is a great way to circumvent the brain’s natural resistance that kicks in when making life changes. Build up your store of discipline and perseverance before applying it to your goal.
If you’re not already a regular exerciser, try experimenting. Go for a walk after dinner, and then use the same motivational self-talk you used to go on the walk to get going on your other goal. Sometimes it’s easier to accomplish something you don’t really care about than to work on something that’s really important to you.

Gain more energy 
Exercise also gives you more energy, more gusto to live life and attack your resolutions with enthusiasm. It’s an effective antidote to depression, clearing up any sadness that may be responsible for hindering your success in reaching a goal.
Even the difficult accomplishment of quitting smoking is made easier by exercise, researchers have discovered. Scientists at the Concordia University found that people who have an especially difficult time kicking the habit are likely to have undiagnosed mental health issues.

Meanwhile, people who are depressed tend to smoke more cigarettes than those who aren’t. About 40% of people with depression smoke cigarettes regularly. People with depression are more likely to smoke and find it harder to quit. Quitting is tough. It can cause insomnia and lead to food cravings or anxiety. Researchers say people without mental health issues are better able to ride out those difficult times than people experiencing depression.

Meanwhile, the Concordia researchers found that exercise can make those cravings easier to overcome, and it can also help lift feelings of depression. Exercise releases feel-good hormones called endorphins and helps reduce anxiety. Study coauthor Gregory Moullec says: “Our hope is that this study will continue to sensitize researchers and clinicians on the promising role of exercise in the treatment of both depression and smoking cessation.”

Lift your mood 
Exercise not only lifts the mood, but it can make you feel healthier. Those healthy feelings can help a person adopt other, healthy habits, according to researchers at Queensland University of Technology (QUT). Professor Debra Anderson says:
“Studies clearly show moderate to vigorous intensity activity can have mental and physical health benefits, particularly when part of broader positive health changes.”

The QUT study specifically focused on the health benefits of exercise for older women. Doctors traditionally recommend 30 minutes of moderate exercise daily, but QUT scientists say that 30 to 45 minutes of high-intensity activity, marked by “huffing and puffing,” five days each week is the best way to promote good health.

Engaging in such vigorous physical activity prolonged study subjects’ lives, but also improved their mental well-being, making it easier to achieve other goals and resolutions.
Although gentle forms of exercise, such as walking, are frequently recommended to older people, Anderson says the women she works with also jog, hike, swim, and ride bikes. Adopting a home-based exercise regimen that’s easy to incorporate every day helps to promote consistency, she adds.

Physical activity brightens the mood and energizes the body, providing extra momentum for making positive changes.

Capture the mind and the body 
QUT researchers aren’t the only ones who found that exercise prolongs life. Doctors at the University of Zurich found that people who don’t eat healthy or exercise are 2.5 times more likely to die at any given time. Study author Eva Martin-Diener says:
“A healthy lifestyle can help you stay 10 years’ younger.”
The idea is that by keeping the body as healthy as possible, you’ll be able to achieve other life goals. Fitness dovetails nicely with other healthy resolutions. For example, the desire to eat healthy can be a natural outcome when exercising frequently. The body moves more easily when fueled with easily digestible food.

Exercise has also been shown to improve concentration, according to Harvard Health Publications. Regular, moderately intense exercise causes the brain to release a chemical called brain-derived neurotrophic factor that promotes alertness, sharpness, and improved memory. That means if you’re trying to accomplish work tasks or important personal projects, regular exercise could give you the mental boost you need to excel.
Exercise promotes mental acuity, making it helpful for completing creative projects or work endeavors.

Capture your New Year’s resolutions in 2018
While exercise can be a useful tool for helping you to achieve other resolutions, keep it simple. If you totally exhaust yourself at the gym you won’t have much energy or time left over for other goals. Similarly, we each only have a certain capacity for change at any given time. If you use up all your mojo on exercising, you won’t have much left over for making other positive changes.

Similarly, if you create 20 perfectly-crafted SMART goals, there’s a big risk you’re going to get overwhelmed and quit all of them.

If possible, choose an activity that nourishes you and that’s relatively simple. You might walk, ride a bike, or go for a hike and spend time in nature. Do things that give you more energy and leave you feeling built up and ready to conquer the world.

• Excellent article from our colleagues at the Arizona Pain Clinic 1/2018

Hope this was a good read for you. 

Take care, 

​Dr. Rafe Sales 

I am sure many of you in the Northwest have seen the news articles relating to Steve Kerr, coach of the Golden State Warriors, who had recently undergone a procedure to repair his cerebrospinal fluid leak. This occurred nearly 2 years following his back surgery. Many of the newspaper articles described his experience with debilitating back pain and headaches.  I have had many friends and family ask me what caused this so I thought I would pass on my explanation. 

First, let us start with anatomy, cerebrospinal fluid (CSF) is a clear liquid that surrounds the brain and spinal cord providing a cushion as well as nutrients and immunological protection.  The fluid is held in place by a lining called dura.  When there is a tear in the dura and CSF leaks out, there is a decrease in fluid and pressure. This decrease can lead to severe headaches that often resolve with lying flat.  A spontaneous leak is very rare.  This is most often caused by trauma or a history of intervention that leaded to puncturing of the protective coating to obtain fluid. An additional way this can happen is from previous scar tissue buildup that adheres to the dura.  With scar tissue formation this can later be torn with significant activity this can pull causing a tear. 

Coach Kerr suffered from a tear following a lumbar surgery. One article quotes Steve saying that back surgery should always be avoided.  I agree with this to some extent.  Rehabilitation and every method of conservative treatment should be attempted before undergoing any surgery.  The side effect that Steve experienced is extremely rare and should not be used to guide medical decision making.  This was one person’s unfortunate experience.  The Orthopaedics & Traumaology: Surgery & Research reports that the chance of a dural tear for lumbar surgery is less than 2%.  Most often dural tears occur during the surgery itself when scar tissue, bone, or disc material has actually adhered to the dural and when corrective surgery is performed.  This tear is then sutured and possibly “patched” with a special material to stop the leak of fluid. 

It is important to know the risks and benefits prior to undergoing any medical procedure or surgery.  There are even significant side effects for some people for something as simple as allergy medication like Benadryl.  It is important that each patient is aware of these possible side effects and notify their provider if they believe the medication may be causing new symptoms. 

Many of my patient’s come in with stories of someone that they know or are acquainted with that had a bad experience. However, as medical providers our job is determine each patient as an individual and what their choices are.  There is not one answer or treatment that will work for every spine patient.  This is why it is important to meet your surgeon and care team and come to a decision together and for the patient to feel comfortable with the decision prior to moving forward with any treatment including surgery.

If you are interested in more information on how to pick a surgeon for you, please see the previous blog from 5/27/16 written by Dr. Sales.

Shaylan Zanecki PA-C
Director of Patient Safety & Clinical Research  ​ 

As I sat down today to work on this month's blog for our website here at Summit Spine, I found myself having significant difficulty focusing because I currently have back pain.  Yep, classic acute back pain. I hurt myself 2 days ago and now, as my wife told me this morning, I am a little irritable.  I have had very fitful sleep and daytime pain, but fortunately heavy doses of ibuprofen have been helpful.  At this point, I am questioning whether I should avoid exercise over the next week and if I should add any additional medication.  Maybe I should cancel this afternoon’s clinic and go back to bed?  I treat back pain every day, but I found myself wondering if I am up to date with the latest recommendations.

Lower back pain is now the #1 reason patients seek treatment from their primary providers.  According to the American College of Physicians (ACP), 1 in 4 people in the United States will experience back pain in the next 3 months.  I can’t argue with that! Well, it just so happened that the ACP released their new recommendations for acute and chronic lower back pain in February and there are some interesting changes.  

First, there are a few details and terms we should review.  In medicine, treatment is constantly evolving based on the latest research, clinical findings and technological advances.  This ongoing effort allows us to offer patients the most effective and cost efficient treatment, and is the foundation for evidence based medicine.  Today I will be discussing a “treatment guideline” which is a tool we use to help direct care in the most effective manner.  Guidelines are provided by internationally respected organizations composed of highly reputable researchers, who have done much of the leg work for us.  They often spend several years compiling data and reviewing, sometimes thousands of studies, as the basis of these guidelines.  

In this guideline from the ACP there are a few terms we should also discuss.  When dealing with back pain, the ACP defines acute as lasting up to 4 weeks, subacute as 4 to 12 weeks and chronic as longer than 12 weeks.  There are 2 important points to make here.  First, the overwhelming majority of patients will NEVER get to the chronic phase of injury and most of us accomplish this without any intervention from the medical community.   I guess that means I should stick around for clinic this afternoon.  Secondly, as your pain transitions to a different phase, so does your treatment.   I make this point because what may or may not be indicated during the acute or subacute phase may be considered beneficial during the chronic phase.  Acetaminophen is a good example of this. 
​
For me the most significant change is the use of Acetaminophen.  For as long as I can remember this was a first line drug for back pain and was reinforced by the ACP in their previous guidelines from 2007.  In its latest edition, the ACP found that it did not perform better than a placebo and only offered a weak recommendation for acute and subacute back pain.  Remember though for chronic pain this is a different story and it is still a first line medication for the treatment of arthritis. 

A second significant change is a very solid reinforcement of the benefits of NSAIDS.  These are medications such as Ibuprofen, Advil, Alieve, Naproxin, and Celebrex.  These medications have again proven to be very beneficial and received a strong recommendation.  I can attest to that!  This is not necessarily a change, but this class of medications now seems to take center stage in early treatment.  In addition, muscle relaxants have been endorsed by the ACP as a first line medication during the acute and subacute phase.  Prior to this the consensus had been mixed. 

What I appreciate the most about this new guideline is more focused attention towards non-surgical and non-pharmacological treatment options.  First line treatment includes exercise, physical therapy, multidisciplinary rehabilitation, acupuncture, stress reduction, tai chi, yoga and spinal manipulation.  Each of these areas showed benefit, but one was not more beneficial than others. 

You may have noticed I have not mentioned Narcotics.  Narcotics are not indicated with most acute low back pain and are not beneficial in long term back pain management.  Narcotics work by overwhelming the entire central nervous system.  These effects decrease overall function and can lead to increased dependency, depression, pain and even death.  We will talk more about this in future blogs. 

You may have also noticed this guideline does not include back pain with other symptoms such as leg pain, weakness, or certain times of associated bowel and bladder dysfunction.  These symptoms suggest a completely different problem which can be much more severe and you should see a provider as soon as possible. 

I have included a link if you would like to review the entire article and guideline published in the Annals of Internal Medicine but I also added the summary recommendations below if you want a quick review.  Well I am off to do some light tai chi and take my NSAIDS before clinic, but if you have any additional questions please come see us at Summit Spine.  We are here to help!


Sean Brown PA-C
Director of Patient Education & Clinical Research​

https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain

Annals of Internal Medicine ACP Low Back Pain Recommendations February 14, 2017

Recommendation 1:
Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)
Recommendation 2:
For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)
Recommendation 3:
In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

1. Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. [Epub ahead of print 14 February 2017] doi: 10.7326/M16-2367

​The North American Neuromodulation Society defines neuromodulation as the direct stimulation of nerves by electrical stimulation.  I want to stress that this is NOT a TENS unit!  This is a surgically implanted device used to “interrupt” pain signals to the brain.  This stimulation does not cause muscle contraction or interrupt sensory input such as touch.  The patient will have full sensation and function without the pain when the unit is on.  For instance, if a patient stubs their toe they will still feel the acute pain.  However, if the patient suffers from arthritis or neuropathy in the lower limbs, the spinal cord stimulation will improve this pain.
 
This therapy is appropriate for a broad range of individuals that suffer from back pain, neck pain, complex regional pain syndrome, and neuropathy to name a few. It is an option for patients that have failed to receive relief from previous surgery, if the patient is not a good candidate to undergo a larger surgery, or if there is no other clear surgical option. The spinal cord stimulation (SCS) device is reversible and adjustable. Generally the SCS device is placed directly in the spinal canal; however there is also now a version called dorsal root ganglion stimulation where the stimulation electrodes are placed on one specific nerve that may have been damaged and is now causing chronic pain. 
 
Before the SCS device is implanted, patients undergo a trial period of 4-5 days where a pain management physician or anesthesiologist will implant a smaller electrode version with a needle into the thoracic spine under x-ray guidance, and an external device (generator) is worn for a short period.  This trial allows patients to try the technology before undergoing any surgery to determine if it is the correct treatment for them.  If this trial goes well, then it is possible to move forward with the permanent placement of the SCS device.  We use the word permanent however this device is removable with a small surgery. 
 
Patients that undergo SCS treatment experience decreased pain and improved mobility. This leads to an improved quality of life.  This technology is not one size fits all and is programmed specifically for each patient’s pain.  Patient’s pain can often change over the years and the SCS can be adjusted for this change in pain or symptoms.  When the SCS is turned on, some patients may experience a slight buzzing or tingling sensation called paresthesia.  However, there are now several high frequency options that do not cause any paresthesias but only a lack of pain when on. Inability to undergo MRI if needed was another disadvantage of SCS treatment, however this is also no longer a concern as there are new MRI safe versions of SCS available.
 
The SCS surgery itself is approximately 45-60 minutes performed under general anesthesia.  There are 2 incisions made: one vertical incision that is mid-thoracic (ribcage area) and one horizontal incision at the right or left flank.  It takes several weeks to recover from this surgery.  Bending, lifting, or twisting should be limited while the incisions are healing and soaking bath tubs or hot tubs should be avoided to reduce the risk of infection. 
 
The SCS generator needs to be replaced approximately every 7-9 years depending on brand and usage.  We perform this procedure frequently since patients do not want to discontinue the therapy.  This therapy often allows patients to greatly decrease their narcotic pain medication use to eventually be narcotic pain medication free. There have been many advances in SCS over the last 10 years and this technology overall has been used for several decades.
 
Many of our patients go through with the trial and cannot wait to get the unit placed with surgery!  Recently one of our elderly patients (over 90 years old) that underwent this surgery came in for her one month post-operative appointment and gave me a hug because she was now able to stand without pain for long enough to cook herself dinner.  This unit gave her back her independence and ability to care for herself without pain. 
 
There are several companies in the United States that offer this technology; Boston Scientific, Nevro, St. Jude’s, and Medtronic.  Please see the end of this blog for their website information.  Please contact our office if you have any questions about SCS therapy.

Thank you!

Shaylan Zanecki PA-C
Director of Patient Safety & Clinical Research  ​ 



Suggested Links:

• Boston Scientific: https://www.bostonscientific.com/en-US/Home.html

• Medtronic: http://www.medtronic.com/us-en/index.htm
• St.Jude’s:https://www.sjm.com/en/patients/chronic-pain/managing-chronic-pain/spinal-cord-stimulation?alert=DeepLinkSoftAlert&clset=af584191-45c9-4201-8740-5409f4cf8bdd%3ab20716c1-c2a6-4e4c-844b-d0dd6899eb3a
• Nevro: http://www.nevro.com/English/Home/default.aspx
• 10 Things to Know About Neuromodulation by North American Neuromodulation Society: https://www.neuromodulation.org/LinkClick.aspx?fileticket=4QF5qkX74Q0%3d&portalid=0 

• International Neuromodulation Society:  http://www.neuromodulation.com/

 

Are you one of the 1.9 billion adults battling obesity?  Do you also have back pain?  
This is no coincidence.  I am sure many of you are like me and celebrate by eating; eat when I’m sad and love to socialize around food.  Jim Gaffigan, my favorite comedian, said it best; “I haven’t been hungry in 12 years.”   In our society poor food choices are everywhere we look and often disguised as a “healthy choice”.   I often argue we would be better off as #2 on the food chain.  A little extra motivation to skip Dairy Queen on the way home from the office if a bear is hiding around the corner.  Remember you only need to run faster than the other guy!

In my practice, I have the “Obesity Discussion” with my patients every day.  Often the response I get is, “Well, I would lose weight if my back didn’t hurt”.   The honest question I want my patients to ask themselves is “Was I obese before my back pain started?”   This is a very difficult, but necessary dialogue to have with yourself.  If you do not recognize the role your weight plays in your daily back pain then you will not modify your behavior after treatment.  Sadly, many studies show us that not only patients fail to lose weight following spine surgery; many GAIN even more weight after surgery. (1,2)  This is very disheartening as many patients go through the turmoil of spine surgery and rehabilitation only to return a few years later with similar symptoms.  Unfortunately, they are just as heavy, still have arthritis, and wonder why this keeps happening to them.   But, all is not lost!  I strongly believe this is a failure on several fronts and one we can fix together.  As a provider, I need to spend more time educating my patients that diet and exercise are necessary components to spine surgery.  As a patient, you need to accept that lifestyle changes are required in order to have a complete recovery and to avoid future surgery.  These lifestyle changes need to start before surgery and continue after surgery. 

BMI
It is very important for patients to understand how their weight is measured and considered in surgery.  In medicine, we use BMI (Body Mass Index) as a tool to determine if a patient is healthy weight.  The BMI is a measure of body fat based on weight and height.  The formula is your weight in kilograms over your height squared in centimeters.  Simple right? Not really, but you can do what we all do and “google it”.  There are plenty of apps or websites that will do the calculation for you.  Is this BMI a perfect indicator?  Absolutely not, but it is a simple and standardized tool that serves as a point of reference.  Don’t get caught up in the labels you get thrown into.  For example, you exercise and watch what you eat but never been below “overweight” which is BMI of 25 to 29.9.  I know this can be very frustrating, however forget the labels and just focus on dropping that number.

How Much Weight Should I Lose?
Anything!  I’m not kidding! We will take anything!  This is because of the way even a small amount of abdominal weight translates exponentially into strain on your back.  Imagine taking a 10 lb dumbbell and strapping it to your belt.  Then go about your day.  Would that be comfortable?  How good would it feel to take that dumbbell off and drop it on the floor?  Ahhhh! What if it was a 20 or 30 lb weight?  Even better right?  The benefits of weight loss happen immediately.  Abdominal weight specifically is a large force pulling your lower back (lumbar spine) over your pelvis and towards the ground.  This leads to increased strain in your lumbar discs and small joints at each level in your lower back called your facet joints.  This is an unnatural strain that your body cannot accommodate and it leads to lumbar disc herniations and accelerates arthritis.  

How Should I Lose Weight?
First and foremost, you have to commit to a lifestyle change.  In the modern age we have done some pretty crazy things to make losing weight easier.  Heck!  We even used to ingest tape worms to do the work for us.  Other than severe anemia, abdominal cramping and pooping worms, it worked great!  You may have tried less extreme measures like Atkin’s, South Beach Diet, No Carb, even just eating Watermelon for several days!  Sadly, the only proven long term weight loss plan is lifestyle change, diet, and exercise.  We need to accept the fact that a 1400 calorie Bloom’in Onion at Outback Steakhouse is not acceptable for human consumption even though they will gladly serve it to you. 

So where to start?  Everyone is different.  How overweight are you?  Can you walk 2 miles? Do you also have knee pain?  Do you have heart or lung disease?  My point is that we all have different starting points so talk with your primary provider or us and we will come up with a plan that works for you.  In the meantime, look at your activity level.  Are you putting more calories in than you are putting out?  If you cannot exercise because of your pain then you need to adjust your caloric intake and stop the downward spiral.  

Diet
Recent studies show that diet is the most important factor in successful weight loss.  I’m not talking about eating carrots for the rest of your life.  I am talking about looking seriously at how much fat, sugar and calories are in your diet every day.  You will be surprised!  A general rule to follow is to shop the perimeter of a grocery store.  If you imagine most stores; the meats, dairy, cheese, grain, fruit and vegetables are all around the outside.  All the processed, high calorie food is in the middle.  How much food should you consume? It is based on your age, gender, and current weight.  The American Heart Association has an excellent calculator to help you with this. 
https://www.heart.org/HEARTORG/HealthyLiving/FatsAndOils/Fats101/My-Fats-Translator_UCM_428869_Article.jsp

Want help reading labels? Check out this helpful website:
http://www.mydailyintake.net/nutrients/

Exercise
Yup, you have to do it!  With regards to your back, muscle fitness is essential.   Your spine is just scaffolding wanting to blow over.  Your deep stabilizing muscles help maintain space for nerves and keep you up and moving.  As your pain increases, it is human nature to move less.  The structural benefits these muscles provide are lost when the muscle atrophy and as a result the pain gets worse.  This increased pressure through the spine raises your risk of lumbar disc herniations and/or accelerated arthritis. 

So what should you do? Again, since we all have different starting points you should discuss this with your provider.  Generally, we love it when our patients walk.  It is a low impact, healthy exercise but let’s be honest, may be boring as hell.  One helpful tip is to watch your favorite show or listen to a good book while exercising.  The rule is however, you can only watch or listen when you are exercising.  This is a little extra motivation to start the exercise and then it will be over before you know it!  You might even want to go a few extra minutes to get to that next chapter!  Another option is to try something new.  Ever paddled a canoe?How long since your last hike?  Sign up for a 5k walk.


I hope you find something helpful in this blog.  I want you to remember that we are here for you.  We understand this is not easy.  We are people who love ice cream too!  If it were easy we would not be writing blogs about it!  Please keep checking back for more information regarding obesity and spine conditions, I’m sure this will not be our last post on this topic.
 
Sean Brown PA-C
Director of Patient Education & Clinical Research

​Many of our patients come to us after trying many things for their lower back pain.  This usually includes physical therapy, chiropractic care, modification of physical activity, and various medications. If this is unsuccessful then spine surgery may be an option, but then what? In some cases a fusion is even needed, and this is the largest spine surgery one can have. Therefore there are often lots of questions surrounding this. In this blog we would like to address some of the most common but more obscure questions patients have after surgery.
 
The purpose of a fusion is to take an unstable joint and fuse two or more vertebrae together to increase stability and decrease degeneration.  This can include rods, screws, and a spacer to maintain vertebral height called an interbody cage that often takes the place of a damaged disc. .
 
Here are a few most common questions I receive from patients or their family members following spine surgery: These answers are most applicable to patients undergoing lower lumbar surgery with hardware being placed.  

How active can I be after surgery?
For the first week you should minimize activities which require you to bend at the waist, twist the torso, or lift anything heavier than a gallon of milk, which is about 8 pounds.  This means most household chores, such as laundry or loading a dishwasher will be off limits for the first week or two.  These activities are going to be best done by someone else during this important recovery period. 
 
This time period of reduced movement is to allow the muscles surrounding the spine to heal and avoid injury.  However, most importantly this time period of reduced movement at the location of your surgery will improve better bone formation and increase potential for faster and stronger fusion. 
 
After a week or two when the pain subsides you can increase your activity slowly. We recommend limiting your lifting to less than 30 pounds for the first 4-6 weeks to minimize the risk of pain or implant failure. You will have a brace which supports your back for this period also. If you experience pain with increased activity then slow down and return to your prior level of activity. Then try again in a day or two.
 
After the first month you will be slowly increasing your activity.  I often rely on the old saying ‘If it hurts don’t do it’. This means that it will often take more and more activity before the patient feels discomfort.  This will continue to improve over time but the patient needs to rest when that limit has been reached. 

How often should I be walking?  Each patient is different in the level of activity that they are able to perform prior to surgery so the same goes for after.  Studies have shown the best recovery in patients following spine surgery are those that take multiple walks throughout the day and continue to increase this amount each day throughout their recovery.   Walking is key for recovery from any surgery!
 
It is best to walk at least every 2 hours, during waking hours, even if it is just to take a bathroom break.  This helps to increase blood flow, drain inflammation, prevent pneumonia, and prevent blood clots.  

I don’t want to take narcotics for pain, are there alternatives? Narcotic pain medication was developed for post-operative pain.  The best way to take this medication is as prescribed by your provider.  Once you begin to have decreased pain then you can slowly decrease the amount of pain medication.  Stopping this medication at one time can cause increased side effects.  Any NSAIDs or non-steroidal anti-inflammatories such as Ibuprofen, Naproxyn, Celebrex, Advil or Aleve should be avoided for at least 4 to 6 months ideally after surgery due to the negative effect these medications have on bone growth and your fusion.
 
Narcotic pain medication was developed for post-surgical pain. There has been a great deal of concern of this in the news lately.  The words addicted or dependent are often used.  These medications will be utilized after surgery to help decrease pain.  The best plan is to take the medication as prescribed by your healthcare provider and if there are any questions to call your provider. 
 
I am often told by the patients that their pain improved so they stopped taking the medication “cold turkey”.  Unfortunately, this behavior can increase the side effects if the medication was taken for more than 2 weeks.   I often suggest to slowly decrease the amount of medication as dictated by your pain.  This will minimize both the side effects of the medication and decrease the side effects of stopping the medication.  

Will I set off airport detectors?  This is often a question if there is hardware placed in the neck or lower back: The new airport screening method uses millimeter wave technology, which does not penetrate the skin.  So no you will not set off any alarms if you have hardware placed during your spine surgery.  In the past you received a card showing that hardware had been placed, however these are no longer accepted by security and therefore are no longer needed.
 
What is the best diet to improve healing? I am often asked if there is a supplement or vitamin that will speed healing.  Unfortunately there is not, it is important that you eat healthy to provide the body with proper nutrients to heal. 
 
When will I be able to drive myself? No driving for two weeks after a lumbar fusion. No driving while taking narcotic pain medication. You must be able to act fast for your safety and for the safety of others.

When will I be fully healed?  It takes 12-18 months for bone to grow and form a solid fusion following surgery. If you are not undergoing a fusion, it can still take about 12 months for the nerves that were compressed or irritated to heal.  During this time period the nerves are hyper-excitable or easily irritated. Often the pain following surgery is improved but not completely gone.  We will often refer to the pain following surgery as different and continuing to change.  It is possible for some leg pain to remain due to permanent nerve damage, however this is less common. 
 
In addition, there may be lower back pain present intermittently. This pain is often due to arthritis throughout the lumbar spine at locations other than your fusion.  This is due to age and wear and tear over time. 

How do I know if I am “fused”?  A “fusion” is designed to take a joint that causes pain and reduce its movement.  This is done by placing hardware and overtime bone growth solidifies this.  How do we know when this has occurred? It takes 12-18 months for bone to grow to form a solid fusion following surgery. If your pain remains improved then no further imaging is needed to visualize that the fusion has completed. If the pain was better and then worsens around 12-18 months, then new imaging /CT scan may be needed to determine if there is full bone growth.
 
When can I travel?  Now that travel season and summer is upon us I get asked this a lot.  Anywhere from international travel, family camping trips, to weekend trips to the coast.  This question goes along with with physical activity question, recovery will vary with each patient and depend on the specific surgery.  However, I would recommend not traveling for a minimum of 2 weeks and ideally 4 weeks following major spine surgery. 


Hope you found this month's blog helpful.  Have a great summer!

Shaylan Zanecki PA-C
Director of Patient Safety & Clinical Research  

References:
http://www.pnl.gov/nationalsecurity/millimeterwave/learn_more.stm
http://www.spine-health.com/

When debating what this month's blog would focus on, I was thinking about various ideas. What’s new in spine surgery? The risks and benefits of disc arthroplasty? I couldn't come up with just one great topic. Then yesterday one of my patients asked "why you? Why should you do my surgery?" While frank and to the point, it made me think more about how patients choose their surgeon when they need to go under the knife. And more importantly, how can they find out if their surgeon has any skill?
 
For most people, undergoing  a surgery is one of the most harrowing and scary situations they will face in life. When I had surgery, the hardest part for me was knowing that for some period of time... one hour, two hours, whatever it took,  I had no control over what was happening to me. The helpless feeling was much more then I ever expected. It was an eye-opening experience, and one that made me consider just how I relate to patients that are about to undergo surgery. It also made me think about how I chose whose life and body I would entrust myself to. I fortunately had the benefit of knowing many orthopedic surgeons and knowing their skill, so when I needed surgery I called several of the doctors I trusted most, and then went to whomever could get me in the soonest. But most patients don't have that benefit.
 
Therefore I thought I would try to put on paper how someone should go about choosing their surgeon, and what questions they should ask. Hopefully this serves some benefit to those considering surgery. Not just spine surgery, but any surgery at all. 
 
The first question people should ask, and the one that is most difficult for a patient to truly find out, is the following: Is my doctor a skilled surgeon? Simple question, but incredibly difficult to answer.  25 years ago a landmark study looked at hospitals in NYC, and found a four fold difference in mortality and complication rates across different hospitals, even accounting for variables. (1) That was astonishing, considering that all surgeons are board certified and fully credentialed. On paper they all look great, and all get patients referred to them on a regular basis. When looked at closely, it was found that these hospitals and physicians also had a higher complication rate than others.  
 
The reasons for these results, however, have remained somewhat elusive. Most "quality" measures that the hospitals and government now focus on focus on are what surgeons do before and after surgery; i.e. giving antibiotics, blood clot prevention, and even charting. But even perfect adherence to the protocols and rules have failed to prevent all complications, and more importantly, there are still significant disparities in patient outcomes after surgery.
 
The elephant in the room has always been clear to surgeons, anesthesiologists, nurses, and hospital personnel. Those that work around the operating room clearly understand that there is one factor that cannot easily be measured, but most likely makes the most difference between a great outcome, and a not so great outcome, that is a surgeon's skill.  
 
For example- imagine that the NBA was run like a neurosurgery, orthopedic, or general surgery program. To determine if you could make the NBA you had to be great at taking tests and memorizing facts.  They had no way to test your ability to put a ball into a basket, jump, or anything like that. Basically you had to be a great student. The only problem is that once you made the team, you had to learn how to play basketball. Then after 5 to 7 years you would play professionally. Can't jump high? No worries. 5’1” tall? No worries. Can't dribble to save your life? You still get to play. 
 
The only difference with this silly analogy unfortunately is that with surgery, patients' lives depend on your skill. Is there anyone naive enough to think that some players would easily excel while others would struggle terribly? Do you think Steph Curry and average Joe would eventually develop the same skill, or would one always be quite a bit better than the other?
 
Several years ago there was the first study showing that surgeon skill actually directly impacted patient outcomes.  The Michigan Bariatric Surgery Collaborative, an innovative collaboration between researchers, payers and weight-loss surgeons, has addressed that which-could-not-be-named. And their findings have confirmed what patients have long suspected and trainees have long known – the dexterity of a surgeon’s hands can account for much of the differences in how well patients do (2).

Researchers from the group asked a panel of surgeon-experts to review videotapes of operations performed by 20 unnamed surgeons who were part of the collaborative. They then asked the surgeon-experts to come up with a ranking based on the deftness with which operating instruments were used, the gentleness with which tissues were handled, the degree to which the surgeons were able to expose key areas, the time and amount of movement required to perform each step and the general flow of the operation. The researchers then confirmed that the rankings remained consistent by asking a different group of surgeon-experts to evaluate the videotapes.
 
To the researchers’ surprise, there were huge variations in operative skill between the practicing surgeons, with the lowest ranked surgeons working at what the reviewers considered a level only slightly better than a trainee at the end of residency, and the highest-ranking surgeons working like “masters” in their field.
 
“You didn’t have to be an expert to see the difference,” said Dr. John D. Birkmeyer, a surgeon who is lead author of the study (4). Dr. Birkmeyer and his co-authors then reviewed the records of the 20 surgeons’ post-operative complications and compared them with their rankings. Not surprisingly, surgeons in the bottom quartile took 40 percent more time to complete the same operation and had higher mortality rates than top-ranked surgeons. But their patients also ran a significantly higher chance of developing a whole host of complications, including wound infections, pneumonia, bleeding and thrombophlebitis, and required re-operation and readmission to the hospital after discharge more often than patients of surgeons whose rankings were in the top quartile (2).
 
The study is the first to reliably measure operative skills in practicing surgeons and correlate those measurements with patient outcomes. “We now have a scientific way to evaluate a practicing surgeon’s skill that is as reliable as about anything we measure in health care in terms of quality,” Dr. Birkmeyer observed.

So how can the average patient evaluate their surgeon’s skill since they cannot watch them in surgery?  Here are 5 ways to dig a little deeper before surgery. 
 
1) First of all, ask your surgeon for their complication rates. What is your rate of infection? What is your rate of readmission to the hospital? Success and failure rate?

Any good surgeon should be able to give you these numbers right off the bat. We at Summit Spine can cite these numbers because we follow these closely.  In 2015 we did 452 spine surgeries with 0 infections and 2 readmissions for minor complications.  In 2016 we are on pace for nearly 500 spine surgeries, still without an infection (knock on wood). Our patient satisfaction for most procedures is well over 95%. 
 
2) The second question is How many of these surgeries do you do a week/ month/ year?

It is well known that the number of cases done directly correlates to complications rates. In 2004, a study showed 5 times as many complications with a relatively simple spine surgery based upon the number of cases performed (3). Just like it would make sense that you would want your mechanic to have worked on a car before and not just watched the YouTube video, you want your surgeon to have significant expertise and experience in their field.  As noted above, we did 452 spine surgeries last year, and have averaged over 400 a year for the last five years. While 400 is certainly not a magic number, it does indicate experience and efficiency. I would recommend a surgeon do a minimal of 30 to 50 of a select procedure a year to remain adept and skilled at that procedure. The idea of 10,000 hours has been thrown around a lot in the media lately, but at the end of the day it points to one thing - experience matters.  One esteemed surgeon pointed out "It's not that you have to find the busiest, most experienced surgeon… It’s more about avoiding the guy who does very few of the procedures”.
 
3) Third question,  How long do your patients stay in the hospital? How long does the surgery take?

If I told you that two surgeons at hospital A do the same surgery, but it takes one 5 hours and the other 2 hours, who would you prefer? Speed is certainly not the most important factor, but being too slow certainly is. The risk of complications dramatically increases after four hours. This is one of the reasons that we at Summit work efficiently to keep all surgeries to the minimal amount of time to do the surgery well. This also directly effects the length of time in the hospital. We average under 2 days in the hospital for our largest fusions, and most patients go home the same day.
 
4) Fourth question, Do you do exclusively spine surgery (or whatever it may be… knees, hips, abdominal, brain surgery, vascular, etc)?

This is very important, as fields and procedures have become quite specialized. The phrase we always heard in med school was “student of many, master of none”. If you try to do too many case types, you wont necessarily excel at any one. At Summit Spine we do exclusively spine surgery. No brain surgery, no knee or hip surgery, just spine. I think this makes a huge difference at the end of the day, as it allows a surgeon to focus on one area. 
 
5) Fifth ask for References.

You always have the right to ask for references. If you know nurses or other health care personnel you can ask them as well. Usually people can ask around and eventually find someone who can give good information. This information can be invaluable. 
 
That sums up my first blog, and I hope this helps. At the end of the day, there is no magic answer as of yet as to how we can evaluate a surgeon’s skill. Until then we have to use these tips and tricks to better prepare you for a trip to your surgeons office. 
 
And remember, if you aren't sure, I always recommend a second opinion. You wouldn't buy a car without asking around, so why trust someone with your body?
 
Thanks and have a great day.

Dr. Rafe Sales 
 
​
 
REFERENCES

1. Adult Open Heart Surgery in New York State. An analysis of risk factors and hospital mortality raters. Edward L. Hannan, et al. JAMA. 1990;264(21):2768-2774. 
2. Surgical Skill and Complication Rates after Bariatric Surgery. Birkmeyer et al for the Michigan Bariatric Surgery Collaborative. N Engl J Med 2013; 369: 1434-1442
3. The related outcome and complication rate in primary lumbar microscopic disc surgery depending on the surgeons experience: comparative studies. Wiese M et al. Spine J. 2004 Sep-Oct; 4(5): 550-556
4. A Vital Measure- Your surgeon’s skill. Pauline Chen, Oct 31, 2013. NY Times online. http://well.blogs.nytimes.com/2013/10/31/a-vital-measure-your-surgeons-skill/

Did you know tobacco use is bad for you?  Why don’t you just quit? These are questions I am sure you have heard a million times before. Here at Summit Spine we have yet another very important reason for you to stop smoking; one you may not have heard before. 

Nicotine, and its 4,000 other chemical friends found in cigarettes, are known to slow wound and bone healing.  This may lead to severe adverse outcomes in spinal injuries, degenerative conditions and elective spine surgery.  For the purposes of this discussion I will mostly refer to tobacco abuse as “smoking”.  If you “chew” or “vape”, keep reading because you are in the same boat!

Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin and bone.  This can cause “tissue ischemia” and impair healing of injured tissue which leads to infection.  Spine is the foundation for the body; consider it the “tree trunk” that supports all other activities. It does not have large blood vessels to draw nutrients from, but instead it is fed by millions of smaller vessels.  These vessels are most susceptible to the effects of Nicotine because they squeeze closed after its consumption.  There are also other chemicals such as Carbon Monoxide and Hydrogen Cyanide that inhibit the bodies natural reaction to injury which can further slow healing. 

In the case of a fusion, you have a certain amount of time to “fuse” the bony segments before your body will essentially give up and wall the areas off into separate segments.  This leads to what is called a “non-union” and/or “hardware failure” which may lead to additional pain and the need for revision surgery.  It is generally felt that in a healthy individual, a fusion would be complete in 12 to 18 months.  In patients who consume tobacco, we know this process takes much longer and the risk of a non-union is dramatically increased. 

Okay, Okay time to quit.  You may have tried before and FAILED!  Well don’t be so hard on yourself.  Quitting is a process with many ups and downs.  Here at Summit Spine, we understand that this is no easy task.  Successful smoking cessation is all about preparation and patience.  First and foremost is to understand that you have two addictions; physical and habitual.  Often times when people fail quitting, it is because they are only addressing and planning for one of these. 

Physical Addition is the area most people focus on.  This is often treated with medication.  There are several products available to consider. 

• Wellbutrin is a mood stabilizer that may be effective in managing the anxiety and mood swings which are common when withdrawing from nicotine. 
• Nicotine patches and gum can also be effective.  They allow you to taper the amount of nicotine in your body by “weaning off” the chemicals.  Please keep in mind though that the nicotine from patches or gum still slow the healing of the bone and tissue, therefore plan ahead to ensure you’re done using them before surgery.
• Chantix is an excellent new medication which works on both the physical and habitual addictions.  This medication binds to the nicotine receptors in your brain to release the “happy chemicals” you get from a cigarette.  It also prevents the nicotine you consume from binding to those receptors so you don’t get anything from your tobacco. This leads to less interest in a dip or smoke (habitual dependency) and your life slowly stops revolving around your next cigarette break! 

You should discuss these medications with your Primary Care Provider to see what option is best for you.  Also, these medications may not covered by some insurance so you will have to pay out-of-pocket.  Consider taking the funds from your tobacco budget since the average smoker spends over $1500/ year on tobacco produces. 

Habitual Addiction, in my opinion, is often ignored and is the #1 reason why you have failed in the past. Smokers often say “I quit for 3 months but then I lost my job so I started smoking again”.  This is because you did not address the habitual side.  A dip or cigarette is a “comfort blanket” for when life throws you a curve ball and not planning for those urges down the road will lead to failure.  This is where counseling comes in. Having someone help identify your triggers is essential.  Fortunately this is a simple process.  The Oregon Quit Line is one resource that you can tap into for free.  People who access this option increase their chances of quitting by 18-20%.  If you combine this with medication, your chances double! 

You can go to www.quitnow.net or call 1-800 Quit Now for more information. 

At Summit Spine, we know this is not easy.  If you are reading this you most likely are in pain and considering surgery.  We need for you to understand that surgery is only one small portion of your treatment plan and overall success.  You need to take steps to optimize your physical and mental well-being before, during and after surgery.  This means you need to obtain support from family and friends, eat healthy, exercise, actively participate in physical therapy and STOP SMOKING!  If you need help please ask, we are here for you.  

Sean Brown PA-C
Director of Patient Education & Clinical Research

The risk of post-operative skin infections following a surgery was found to be approximately 2% according to the Scoliosis Research Society that presented at the 24th Annual Meeting of the North American Spine Society.  Here are a few things that you can do to prevent superficial skin infection of your incision:

• Wash bed sheets prior to surgery
• Do not allow pets to sleep in bed with you
• Shower with soap daily allowing soapy water to travel over the incision
• Do not use nicotine
• Make sure that anyone assisting you or yourself wash hands before dressing the incision
• Do not use antibacterial creams
• Do not shave the area prior to surgery
• Call your surgeon if you develop a fever greater than 100.1 degrees F , develop drainage or increased redness surrounding incision

 
These are a few things you can do to reduce your risk.  If you have any questions please do not hesitate to contact your healthcare provider or visit:
https://www.nlm.nih.gov/medlineplus/ency/article/007645.htm  for further information.

Shaylan Zanecki PA-C
Director of Patient Safety & Clinical Research