Panorama Orthopedics Blog
Surgical Options for Neck Pain
Dr. Pushcak
May 23, 2013
According to a recent presentation by Dr. Thomas Puschak, a spine surgeon with Panorama Orthopedics & Spine Center in metro Denver, 90 percent of patients with neck pain don’t require surgery.
That’s good news! It’s also good news that surgical options are available for the remaining 10 percent of patients who do need it.
So when do patients know it’s time to start considering surgery?
“Typically, if there’s no neurologic or motor deficit, we’d like to see a good six- or eight-week span to see that this isn’t something that is going to pass relatively quickly with some simple non-operative treatment,” Dr. Puschak said. “Certainly, if somebody has significant weakness, that is something that could kick us up to a more aggressive route.”
In cases of spinal cord dysfunction where there is a neurologic or motor deficit, Dr. Puschak said that holding off on surgery might not be an option.
“We would move toward something surgical quicker because waiting on that could lead to permanent problems that could become nonreversible,” he said. “In worst-case scenarios, spinal cord dysfunction can lead up to paralysis.”
The vast majority of patients over time are able to achieve pain relief through some combination of medication, injections and manual therapies such as physical therapy. However, patients must work with their doctors to achieve the best results for their individual circumstances.
“Nerve pain can be quite intense. And it varies, it’s different for every person,” Dr. Puschak said. “Sometimes it can be annoying and a nuisance, sometimes it can be debilitating. You may have a normal motor exam, but your pain is so out of control that you can’t do things on a daily basis. The concept of going through all of those other things for six or eight weeks might not be realistic for someone.”
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Panorama Orthopedics Blog
Options For Addressing Neck Pain
Dr. Puschak
May 14th 2013
If you are a patient who suffers from neck pain, here's some good news: Most of you don’t need surgery.
“More than 90 percent of neck problems can get better long-term with non-surgical treatment,” said Dr. Thomas Puschakof Panorama Orthopedics & Spine Center in metro Denver. “Most people who are going to come to see me are going to find ways to maintain and manage these symptoms.”
That was music to the ears of most of the patients in attendance at Dr. Puschak’s educational seminar on common neck and spine conditions.
Treatment options for neck pain and numbness include medications, such as nonsteroidal anti-inflammatory drugs; injections, such as epidural steroid injections and selective nerve injections; and manual therapies, such as physical therapy or chiropractic treatment.
“Medications are looking to decrease the inflammation cascade that will go along with these degenerative changes,” Dr. Puschak said. “A mix of mobility work, along with strengthening and conditioning, can often times make a lot of these symptoms better. Certainly, if the oral medications and therapy aren’t working, the injections can help get ahead of that pain and help avoid surgery in some situations.”
Dr. Puschak said that most of these treatment strategies are designed to buy patients time until the symptoms naturally diminish on their own.
“Most of these symptoms, or most of these syndromes that flare up, despite how intense they can be, are going to calm down in time,” Dr. Puschak said.
There are always some instances where this is not the case and surgery may be required. It is also important to note that surgery may be needed if the condition is more severe, as is the case with spinal cord dysfunctions.
If tingling, numbness and weakness are present in other areas of the body, and it leads to difficulty walking or decreased coordination, it could indicate a more significant problem.
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Help for Curvatures of the Spine
Dr. Agarwala
May 13, 2013
Medical conditions such as scoliosis, kyphosis and spondylolisthesis require the kind of treatment that you would only trust to the experts.
“The surgeons at Panorama have a great deal of experience with complex surgery,” said Dr. Amit Agarwala of Panorama Orthopedics & Spine Center in metro Denver. “In fact, many complex revision surgeries are referred to Panorama Orthopedics when things have not gone ideally elsewhere.”
Dr. Agarwala specializes in treating spinal deformity conditions. He regularly treats patients with conditions such as:
- Degenerative scoliosis, in which a patient’s spine curves to the side. “This type of curvature can lead to patients feeling crooked, or not feeling balanced,” Dr. Agarwala explained. “In addition, it can lead to significant lower back pain because of the shortening of their lower back and some proximity of the ribs to the pelvis because they are losing length in their midsection.”
- Kyphosis, a condition that results in an abnormally rounded spine that can give the appearance of a hunch or “dowager’s hump.” “It makes it painful for folks because they can’t stand straight,” Dr. Agarwala said. “Often times the spinal deformity forces them to lean forward in this direction.”
- Spondylolisthesis, in which vertebrae become unstable and cannot hold their correct position. “Vertebrae start to actually shift,” Dr. Agarwala explained. “This can cause a lot of back pain, as well as pinched nerves that cause leg pain.”
Dr. Agarwala emphasized that while surgery can benefit patients suffering from a spinal deformity, it is a big decision that is never taken lightly.
“We only recommend surgery when all other treatments have failed,” he said. “However, successful surgery will lead to a longer ability to stand upright, walk distances without pain, and remain more active. Many patients without surgery succumb to their symptoms and become more sedentary, unable to stand or unable to walk for any length of time.”
Panorama Orthopedics & Spine Center is committed to helping patients feel better so they can do more of what they love.
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Panorama Orthopedics Blog
Common Neck and Spine Conditions
Dr. Puschak
May 8, 2013
Written by Panorama Orthopedics
Necks, spines and ... cars?
Dr. Thomas Puschakof Panorama Orthopedics & Spine Center in metro Denver recently jumpstarted a presentation on common chronic neck and spine issues with a car analogy.
“It’s like driving a car off of a lot,” Dr. Puschak explained to his audience. “As soon as it’s off of the lot, these kinds of wear and tear things start going on.”
Dr. Puschak was referring to the toll time takes on the neck and spine.
As we age, the disks of our spine lose water content, beginning a process that can eventually lead to spine and neck problems such as arthritis, pinched nerves and bone spurs.
“Over time, the disks will start to dehydrate,” Dr. Puschak said.
This can lead to a loss of height and a straightening of the spine, and can create an opportunity for arthritis to set in. If the cartilage between the disks wears down completely and the disks rub together, that can also result in bone spurs.
Another complication can occur when the portals in the side of the spine also narrow, because the nerves passing through those portals can become pinched.
“As this disk narrows top to bottom, the ceiling and the floor of this hole will narrow and get closer together where the nerve comes out,” Dr. Puschak said.
A herniated disk is also a risk in these circumstances.
Symptoms that might indicate a neck or spine problem are:
- Pain and stiffness.
- Numbness and weakness in the arms, hands and fingers.
- Difficulty walking.
- Loss of balance.
- Muscle spasms.
- Headaches.
- A grinding or popping sound with neck movement.
Just as a perfectly good car shouldn’t be put away for safekeeping out of fear of wear and tear, neither should you. A healthy awareness of when a problem might need attention can keep you in the driver’s seat, enjoying the ride.
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Back pain? Exercises might help 
Dr. Knight
May 6th, 2013
We know exercise is important, particularly core exercise to strengthen abdominal and back muscles. But how can you exercise if back pain makes almost any activity uncomfortable?
The doctors at Panorama Orthopedics & Spine Center near Denver look for ways to make patients feel better, so they can do more.
Dr. Karen Knight, a board-certified physician specializing in spine disorders, recently held a free educational seminar on strengthening core muscles. Dr. Knight emphasized the importance of core exercise, but cautioned patients with back pain to be careful when choosing their routine.
“Many people do core exercises that they have discovered off of the Internet, and many of those are not safe for individuals with degenerative spine disease,” Dr. Knight said.
Some exercises, such as curls and using medicine balls in a twisting fashion, increase the biomechanical stress across the disks in the spine. Extension-based exercises can also narrow the spinal canal in conditions such as spinal stenosis.
Dr. Knight encourages patients who have back pain that is affecting their function or quality of life to be evaluated if they have questions about which exercises to avoid. She recommends exercises to her patients that are spine neutral, some of which are shown here.
“Individuals who see me are already usually in pain so they typically need a structured program,” she said. “All of these exercises are evidence-based. Their goal is to decrease the stress across the disks.”
Even individuals without back pain should use caution when exercising. Dr. Knight says that if an exercise is causing pain, it is possible it is being performed incorrectly, or that there is an underlying medical condition that deserves attention.
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Arm Pain Can Stem from Pinched Nerve
Dr. Puschak
May 3, 2013
It might seem counterintuitive, but arm pain in some cases can actually be caused by a problem in your spine, specifically a pinched nerve.
If that is the case, the path that the pain will paint along your arm can serve as a map that guides doctors to your diagnosis.
“If you have weakness in a specific muscle group, it can lead to suspicions about where the nerve compression is coming from,” explains Dr. Thomas Puschak of Panorama Orthopedics & Spine Center in metro Denver. “The pain will typically go just along the distribution of that nerve. Each individual nerve will map out to different parts of the arm.”
For example, pain in the deltoid or biceps could indicate a pinched nerve in the fifth cervical vertebra, typically referred to as C-5. However, pain in the wrist extension is associated with C-6, pain in the triceps with C-7, and pain in the hand could indicate a pinched nerve located further down the spine.
The medical term for a pinched nerve is cervical radiculopathy. Your doctor can typically diagnose the problem in an office visit that includes a motor exam.
“The motor exam can help clue us in as to which nerve is pinched,” Dr. Puschak said.
While the arm pain associated with this type of condition can be severe, Dr. Puschak puts the diagnosis in perspective.
“This does not involve the spinal cord, so syndromes create a lot of arm pain, usually one-sided, but aren’t very risky as far as spinal cord goes,” he told a group of patients at a recent seminar.
It is important to note that the majority of patients with cervical radiculopathy get better with time and never need surgery, or even treatment. However, non-surgical and surgical treatments are available for patients whose pain does not pass and is unmanageable
.
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Panorama Orthopedics Blog
You’ve heard of hip replacement surgery and knee replacement surgery, but what about ankle replacement surgery?
At Panorama Orthopedics & Spine Center in metro Denver, it is a routinely performed procedure.
“Although it’s not as common as hip and knee replacements, it’s one that we do on a fairly regular basis as an orthopedic foot and ankle surgeon,” said Panorama’s Dr. Premjit (Pete) Deol.
In an ankle replacement surgery, the arthritic bones of the ankle joint are removed and replaced with artificial metal joint parts.
“It’s different than any other type of joint replacement because you’re working with a body part that doesn’t have as much muscle and tissue surrounding it,” said Dr. Deol. “You have to be much more delicate with the surgery.”
Dr. Deol and his colleagues at Panorama utilize special devices outside of the ankle, such as portable x-ray machines, to make sure that the implant is correctly positioned.
“There are special considerations because it’s overall a much smaller joint than a hip or a knee, so there is not as much space in which to place the implant,” Dr. Deol said.
Ankle replacements address the pain caused by severe arthritis and give patients a fully functional ankle joint.
“The biggest surprise for patients is probably the speed at which they can move the ankle without having pain,” Dr. Deol said. “It still takes a full six weeks before they can walk on it, but we get them moving it pretty quickly after the surgery. They soon realize they are not having pain moving the ankle for the first time in several years.”
While ankle replacement patients are typically able to return to all of their daily activities after their recovery, certain other activities may not be possible.
“We try to limit anything high impact that compromises the ankle,” Dr. Deol said. “We let patients go back to hiking and walking and skiing, but when it comes to running, for example, that’s something that we try to have them avoid.”
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Did you know that even minor ankle injuries can result in arthritis that, over time, can make the ankle stiff and painful?
It’s an unfortunate truth, and one that the foot and ankle specialists at Panorama Orthopedics & Spine Center in metro Denver work with all the time.
“With most of the other joints like the hip or the knee, you can get arthritis because of heredity and wearing out of the joint, but arthritis in the ankle is most commonly related to previous trauma that people have experienced,” explains Panorama’s Dr. Premjit (Pete) Deol.
A quarter of a million people every day sustain ankle injuries such a sprained ankle, according to the American Academy of Orthopaedic Surgeons.
Post-traumatic arthritis can develop years after such an injury occurs, if it the injury is severe.
“Unfortunately, there is nothing that can be done to reverse arthritis,” Dr. Deol explains. “It tends to be a progressive disease and over time, it will cause more and more of the cartilage to degenerate.”
Conservative treatment options are available in cases where the arthritis has not progressed to the point where surgery is necessary.
“We’ll start with a brace,” Dr. Deol said. “If patients are limiting motion through the ankle, that will reduce the amount of pain that they have because there won’t be as much bone rubbing on bone.”
Other outside mechanisms can also be used to provide additional support to the joint, such as orthotics or special footwear.
Medication such as pain relievers and cortisone may also help relieve the discomfort.
In cases where a deformity in the ankle is the cause of the problem, correcting the deformity through outside devices such as a brace, or through corrective surgery, may be sufficient to address the problem.
“Sometimes correcting the deformity will take pressure off of the arthritic joint and people will feel better,” Dr. Deol said.
While arthritis may not be curable, it is at least treatable.
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Panorama Orthopedics Blog
When a patient requires hip replacement surgery, Panorama Orthopedics & Spine Center in metro Denver is now able to offer a highly specialized anterior hip replacement option.
This approach uses a high-tech table and a portable x-ray for precise positioning of the hip replacement implant. Together, these tools allow for a smaller incision on the front of the hip, instead of the back or the side, and a quicker and less painful recovery for most patients.
“I can make sure that the components are in the exact right position,” said Panorama’s Dr. William Peace.
Dr. Peace is part of an elite group of surgeons in the country who specialize in the anterior approach to hip replacement surgery, which has been performed since 1947.
Dr. Peace said that the technology that patients have access to today not only makes surgery and recovery more comfortable, but also increases the overall life of the hip implants.
“We are on our third generation of hip replacements,” Dr. Peace said. “The first generation lasted five to 10 years, the second 10 to 15 years. The hope with this new generation is that we can get 20 to 30 years, or even longer.”
That is another reason that Dr. Peace prefers to use the anterior approach to hip replacement.
“The type of hip replacement I use has been around for a long time, and if we look at data from other countries with joint registries, there is a 90 percent success rate at 20 years,” he said. “As physicians, we are always looking for ways to improve our surgeries and get better and longer lasting results.”
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Panorama Orthopedics Blog
For some, it may seem that how a surgery is performed is best left up to the surgeon. However, patients have an important part to play in the decision, especially when it comes to hip surgery.
Surgeons can perform hip surgery either from the front of the hip, the back of the hip, or from the side. Why does it matter? It can impact the size of the incision and the resulting scar, how much the surrounding muscles are affected, and how quickly you recover.
Dr. William Peace with Panorama Orthopedics & Spine Center in metro Denver recently touted the advantages of the anterior approach to hip replacement surgery, with the incision on the front of the hip.
“The anterior hip surgery is a minimally invasive surgery that doesn’t cut any muscle when we do a hip replacement,” Dr. Peace explained. “When we make an incision on the front of the hip there are two muscles that come together, and we go between these muscles. From there, the procedure is no different from a typical surgery.”
The anterior approach to hip replacement surgery is not new, but it is so specialized that it is not always easy for patients to find a qualified surgeon with the proper tools to perform the surgery.
Dr. Peace specializes in performing the anterior approach to hip replacement surgery at Panorama.
“As more people start to see the results of this type of surgery, more surgeons will learn how to do this approach,” Dr. Peace said.
Patients who elect this type of procedure are not faced with the additional pain and time that it takes for injured muscles around the hip to heal. The stronger muscles also increase stability for the new hip and help patients return to normal activities sooner.
“With a normal hip replacement, we put limits on the types of movements and functions that you can do,” Dr. Peace said. “With this, the hip is more stable so there are no limits.”
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