Dr. Musacchio on Minimally Invasive Spine Surgery

Written by Michael J. Musacchio, Jr., M.D.

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Minimally invasive spine surgery (MIS) is best described as a method of performing spine surgery through small incisions with less muscle disruption, shorter recovery times, and with maximal preservation of normal spinal anatomy. While the term “MIS” is used very liberally these days, the MIS techniques really took off in the late 1990’s and early 2000’s with the introduction of tubular retractors and the use of endoscopes and microscopes. Through tubes the width of a finger, MIS surgeons can gain access to spinal pathology (i.e. disc herniations, bone spurs) while minimizing the cutting, stripping, and cauterization of muscles and ligaments which are vital to the preservation of spinal function and the prevention of future problems.

I began my neurosurgical training in a residency program at Rush University in Chicago. The Rush neurosurgical program had committed very early on to the development and teaching of minimally invasive spine surgery techniques. The equipment that we were using at the time was prototypical and very rudimentary. We were using 2-Dimensional endoscopes before High-Definition applied to anything beyond a stereo receiver. The visualization was poor and we had a very limited amount of tools and equipment that was usable through these small tubes. We were spending countless hours in the cadaver labs practicing our techniques and seeing how far we could push the technology. The early results in patient care were encouraging as patient outcomes were excellent and their recoveries were much shorter and much less painful than traditional approaches. This was the beginning of the modern age of MIS spine surgery and I was very fortunate to be at Rush during this time. My very first experiences in spine surgery were operating through tubes, and this impacted my development as a spine surgeon and my decision to commit my entire practice to minimally invasive spine surgery.

Over the last decade technology has exploded. We have more equipment than we know what to do with. Thanks to the development of HD scopes and improved depth of perception we now have unbelievable optics to view the spine. Collaborations between surgeons and industry continue to drive the field and continually introduce new techniques and equipment that enable MIS surgeons to offer better, safer, and smaller surgeries that offer maximal impact to patient outcomes and recovery. Most importantly, there is so much more to develop and perfect in the field as we are really only just beginning.

Plano Profile Magazine recently did a feature story on Dr. Musacchio and his early high school years in the medical scholar program. Read more on how this program helped shape his desire to become a minimally invasive neurosurgeon.

Michael J. Musacchio, Jr., M.D. is a Center for Spine Care minimally invasive neurosurgeon specializing in the spine.

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To learn more about Center for Spine Care, visit our website!

Dr. John Peloza Voted to Best Doctors in Dallas 2011

Congratulations to CSC’s Medical Director, John Peloza, M.D. for being selected once again to the prestigious D Magazine’s “Best Doctors in Dallas” list for 2011! Dr. Peloza has been continuously voted to the Best Doctors list since 2003. Best Doctors in Dallas is a peer-reviewed voting process. The 2011 list includes the top 699 physicians in 43 specialties. The list was just announced at a reception honoring the Best Doctors and is in the current issue of D Magazine.

Doctors can not pay to be on the list. Here’s how it works according to D Magazine: Almost 8,000 letters were mailed to local doctors inviting them to vote in 43 categories with this question in mind: “Which Dallas doctors would you trust with the care of a loved one?”  Then D Magazine vetted each voter’s Texas medical license number to ensure it was valid.  The results were then sent to an outside marketing firm to tally votes. They presented the tallied list to a panel of esteemed physicians who reviewed the results with the D staff and chose the finalists based on the number of votes received in each category. This esteemed physician panel is granted anonymity to encourage open discussion regarding doctors on the list.

Join us in congratulating Dr. Peloza for all of the great, compassionate care he continues to provide his patients as well as his determination and skill to continue pioneering modern, minimally invasive spine treatments!

John Peloza, M.D., is medical director of the Center for Spine Care. Dr. Peloza has pioneered some of the most modern techniques currently on the market.

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To learn more about Center for Spine Care, visit our website!

Using Evidence Based Medicine to Treat Patients with Back or Neck Pain

By Minimally-Invasive Spine Surgeon, John Peloza, M.D.

NFL quarterback Peyton Manning may be out for this season after recent neck surgery. First, a disclaimer, I do not know Mr. Manning or the nature of his spinal condition and I have no role in his care. In his case, traditional treatment has not worked as well as intended; therefore, he sought an unapproved (by the FDA) non-traditional (stem cell) treatment outside the United States. His decision generated a media report and subsequent commentary by researchers regarding stem cell treatments and evidence based medicine. I would like to take this opportunity to discuss evidence based medicine (EBM) and its role in medical decision-making. In a later post, I will discuss the current literature regarding stem cells in spine care.

Evidence based medicine is a scientifically validated methodology developed to help doctors and policy makers make rational decisions with reliable data. It compares two treatments for a specific condition utilizing the disciplined scientific experimental method with statistical analysis. The gold standard is the large, multi-center, prospective, randomized, double blind study. An experimental treatment (investigational group) is compared to well accepted standard treatment (control group). The patients are randomly selected into the two groups to avoid bias. The patients are evaluated with validated outcome measurements or tools before the treatment and at regular intervals after the treatment for up to at least two years (preferably five years). There are strict inclusion/exclusion criteria for patient enrollment, large numbers of patients for statistical significance, multiple centers and doctors to avoid bias or unusual treatment effects. There must be no breaks in experimental protocol and greater than 80% follow up. The results are then analyzed with sophisticated statistical methods to determine if one treatment is better than another (efficacy). Secondary endpoints include complications and sometimes-economic data (costs).

Another concept in EBM is level of evidence. The best study is described in the above paragraph. This is regarded as a Level I study, the highest level of evidence. A level II Study is a lesser level of evidence. This could be a randomized study with some problems (fewer patients, less follow up, breaks in protocol) or a large non-randomized prospective cohort. A large patient cohort would represent a Level III study with the data collected prospectively but analyzed retrospectively. The lowest level of evidence is anecdotal experience (“this is what I like to do and everybody does great”). Then, there is marketing (e.g. testimonials or You Tube videos) that has no scientific or decision making value but can be quite effective even if misleading.

While EBM is essential to good medicine, it has significant limitations that need to be understood so that one can apply studies in a clinical setting. The biggest problem is that the conclusions from a study may not be universally applicable. A study only compares treatments for a specific diagnosis. Real patients usually have more than one diagnosis (especially in spine-e.g. spondylolisthesis at one level with spinal stenosis at another level and degeneration at another level). Patients can also have confounding factors and co-morbidities that effect enrollment or outcomes. Often these studies are population studies that are not applicable to individual patients. There can also be a lack of consensus regarding a standard treatment for the control group. Surgical studies can also be affected by the technical skills of different surgeons. A particular type of statistical analysis (intent to treat) breaks down in surgical studies. Because it is very difficult for surgeons to participate in a surgical study (to avoid lost follow up, breaks in protocol, careful inclusion and exclusion of study patients, variations in surgical skill) only experienced surgeons who are committed to research need to conduct the studies. Last, the cost in terms of time and money for these studies can be staggering. There are limited resources given the number of medical conditions/problems. At the end of the day, a lack of Level I data is not a lack of knowledge or evidence. A clinician brings the totality of knowledge to the patient in order to understand their problem and make a reasonable decision.

Images provided by Medtronic

At the Center for Spine Care, we use EBM every day. All the doctors have extensive experience in research and know the spine literature because they have participated in a significant way. When visiting with a patient, we strive to make a specific diagnosis. We then relate the natural history (what is likely to happen without treatment) of their condition. We then present the patient with the level of evidence regarding treatment for their specific diagnosis. If the patient has multiple diagnoses or co-morbidities, we discuss how these effect the level of evidence to arrive at a more realistic expectation. We have a very detailed discussion of treatment options (utilizing EBM and levels of evidence), potential complications with incidence of risk, recovery, rehabilitation, and cost. We try to identify and prioritize patient goals for the treatment. This may take multiple appointments but the attention to detail is necessary for the patient to make an informed decision. Everyone is an individual with different characteristics and priorities; therefore, we treat our patients as individuals and not statistics.EBM is a useful but limited scientific approach to make medical decisions. It helps organize data in a usable and uniform manner to rationally make individual and policy decisions.  We use it as a foundation in our clinical decision-making. However, it has significant limitations in universal applications because individual patients may not fit the strict parameters of an EBM study. In addition, the cost of these studies can be detrimental to care. Many patients do not have the time to wait for a definitive study (e.g. Peyton Manning or a cancer patient). Many technologies or drugs may be obsolete by the time an EBM study is complete with long term follow up. If information technologies were regulated by the FDA, we would be computing on an abacus and it would cost a million dollars. Decision-making can be effective utilizing many different levels of evidence depending on the quality of the evidence as well as patient priorities. Doctors are not bureaucrats; therefore, we treat individuals not statistics.

John Peloza, M.D., is a minimally invasive spine surgeon and Medical Director of the Center for Spine Care. Dr. Peloza is a pioneer in minimally-invasive spine technologies, a clinical researcher, and patient advocate.

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To learn more about Center for Spine Care, visit our website!

Peyton Manning and His Recent Neck Surgeries

Written by Michael J. Musacchio, Jr., M.D.

For those of us who follow professional football, a lot of attention has been directed to Indianapolis Colts’ quarterback Peyton Manning and his recent neck surgeries. While we at the Center for Spine Care are not at all involved in Peyton Manning’s surgery, we certainly have a lot of patients who suffer from similar neck conditions and think this is a great time to share some general thoughts on neck injuries and treatment options.

Similar to the low back, the neck is subject to repetitive motion and trauma that lead to aging and wear and tear. The aging process may be accelerated in athletes or other activities that involve excessive physical strain. Wear and tear makes the spine and its components more susceptible to injury, and patients can develop significant neck pain or radiating nerve pain as a result. This may present as general aches and pains or more specific radiating nerve pain and deficits, particularly in the arms and hands.

When these symptoms become severe or persistent, an evaluation by a spine specialist can help determine the problem and the treatment options. Fortunately, up to 90% of neck and arm pain will be self-limited and improve without surgery. Physical therapy and anti-inflammatory medications and injections can sometimes make the recovery period more tolerable.

Surgery is typically reserved for one of 4 scenarios:

1. Patients who fail to respond to a 6-8 week course of conservative management.
2. Presence of severe or progressive neurologic deficit, such as weakness or sensory loss.
3. Severe, intolerable pain that does not respond to initial treatment measures.
4. Severe pathology, such as large herniated discs or unstable fractures that threaten neurologic function.

For patients requiring surgery, there are a few options that may be considered. For isolated arm pain that has a distinct disc or bone spur impingement, it may be possible to pursue a minimally invasive posterior decompression that can be done as an outpatient and does not involve fusion. The main advantage of this approach is to decompress the pinched nerve while maintaining the patient’s normal motion to enable quicker return to sports and activities.

Other times, an anterior disc removal and fusion or artificial disc replacement procedure may be required to restore normal alignment in addition to freeing the nerve. Anterior and posterior approaches carry similar clinical effectiveness. However, fusion surgeries tend to delay return to sports and activities longer than minimally invasive posterior decompression.

Rarely will a minimally invasive decompression fail and require subsequent fusion. This is likely the case with Payton Manning, but a full recovery and return to activity after an appropriate course of physical therapy and rehabilitation is typically the norm.

Michael J. Musacchio, Jr., M.D. is a Center for Spine Care minimally invasive neurosurgeon specializing in the spine.

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To learn more about Center for Spine Care, visit our website!

The Importance of Clinical Research/Evidence Based Medicine

By Minimally-Invasive Spine Surgeon, John Peloza, M.D.

As we navigate the future of the healthcare system in America, one thing is a constant. Patients want access to quality healthcare. In the business of spine care, where more than 80% of Americans will suffer from major back pain at some point in their lives, quality care is imperative.

This means offering patients real solutions to their back problems and helping them make informed decisions. This is where the importance of clinical research and Evidence Based Medicine, or EBM comes in. EBM is what we practice at the Center for Spine Care and have for more than 15 years.

EBM is a systematic approach using scientific methods to determine which treatments work best for specific conditions. There is a specific methodology to not only prove the treatment works or not, but also to grade the quality of the studies. EBM is essential to clinical decision making, along with significant clinical experience.

At the Center for Spine Care, we have been involved in FDA trials and clinical research for years and have tracked our own patient outcome data for all of our surgical procedures. Because we know our outcome data, we can help our patients make informed decisions and understand the value (outcome and cost) of their care.

So, if you have back pain, ask your spine specialist for his or her clinical outcomes data. Don’t accept that “all patients get better with this treatment.” Ask to see the data. It could make a real difference for you.

John Peloza, M.D., is a minimally invasive spine surgeon and Medical Director of the Center for Spine Care. Dr. Peloza is a pioneer in minimally-invasive spine technologies, a clinical researcher, and patient advocate.

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To learn more about Center for Spine Care, visit our website!

How to beat the heat and keep your back happy in the hot summer!

Written by Michael J. Musacchio, Jr., M.D.

The recent heat wave in North Texas has made it difficult to get out and enjoy the usual summer activities we all look forward to doing. Unfortunately, it doesn’t look like it is letting up any time soon, so it is important to find activities to maintain an active, healthy spine despite the weather.

Swimming is an excellent activity to keep the back muscles loose and get a cardio boost.

Just wading around the pool is enough activity to make a difference, but you can really push it and get a whole aerobic routine that can rival any land-based workout. Plus, its a fun activity to do with the kids and definitely helps beat the heat.

This is also a good time to join a gym or take a pilates or boxing class.

Organized workouts that engage the entire body are excellent for your back and are typically done indoors in the AC. Another activity is active video games like Wii Fit or others that involve your whole body and give you a good workout while having fun. Always remember that when starting a new workout routine to ease into it and let your muscles get acclimated to avoid injury.

So, despite the heat, it’s important to keep your activity level up to maintain a happy, healthy back.

Michael J. Musacchio, Jr., M.D. is a Center for Spine Care minimally invasive neurosurgeon specializing in the spine.

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To learn more about Center for Spine Care, visit our website!

How to Prevent Back Pain? Lose Weight: Advice from a Spine Specialist who has done it!

Written by Michael J. Musacchio, Jr., M.D.

Obesity is one of the biggest public health issues impacting society, and spine-related conditions are particularly prevalent in overweight patients. The spine is responsible for the structural support of the body and is subject to tremendous loads and strain on a continuous basis. Excess weight and poor core strength lead to increase load and strain on the spine, and this ends up causing injury and pain. I like to use the analogy of a pickup truck. If you drive around all day with boulders in the back of your truck, the truck is going to break down quicker.

Over and over, studies have shown that overweight patients have more back pain and degeneration, and when they lose weight their symptoms improve. Furthermore, it has also been shown that overweight patients are more likely to have complications from spine surgery. So, it makes pretty good sense that the best way to prevent spine problems, and the first thing to treat them, is to lose weight and improve your core strength.

Losing weight and improving core strength is often easier said than done, but it shouldn’t be. Some tips that I give my patients is to find 30 minutes a day to exercise, to cut out fatty foods and sugar-loaded foods, and to set realistic goals. If you say you need to lose 50 lbs in two months, it probably won’t happen or it won’t last. It is better to create permanent, sustainable lifestyle changes like dietary adjustments and daily walks that are enjoyable and not overwhelming. It really is that simple and if you make small adjustments, you will see a difference. Once people get started and see those small steps of improvement it inspires them to keep going and affect permanent change.

Speaking from my own personal experience, I have lost just over 20 lbs in the last 6 months and close to 30 lbs in the last 3 years. I did this by making small gradual changes to my diet, increasing my exercise, and taking small steps to better health as opposed to drastic changes. This way, it has been a sustainable and permanent change that has not been daunting or intimidating.

Michael J. Musacchio, Jr., M.D., is a Center for Spine Care minimally invasive neurosurgeon specializing in the spine.

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To learn more about Center for Spine Care, visit our website!

John Peloza, M.D. selected as one of the 100 Best Spine Surgeons in America

Congratulations to the Center for Spine Care’s Medical Director, John Peloza, M.D. for once again being selected to the prestigious list of “100 of the Best Spine Surgeons & Specialists in America” by Becker’s Orthopedic & Spine Review.

According to Becker’s Orthopedic & Spine Review: 

“Physicians included on the list of 100 of the Best Spine Surgeons and Specialists in America are selected based on surveys, research and nominations. Becker’s Orthopedic & Spine Review endeavors to select spine surgeons and specialists who have committed themselves to the improvement of patient care, quality outcomes and/or clinical and academic developments in the field. All physicians who are placed on the list undergo a substantial review with other peers and through our own research. Physicians do not pay and cannot pay to be selected as a best physician.”

Becker’s Orthopedic & Spine Review is the leading source of cutting edge business and legal information for hospital and health system leaders, owners and operators of ambulatory surgery centers and leaders of orthopedic and spine practices.

Congratulations Dr. Peloza!

John Peloza, M.D., is medical director of the Center for Spine Care. Dr. Peloza has pioneered some of the most modern techniques currently on the market.

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To learn more about Center for Spine Care, visit our website!

Back Pain: Types of Back Injuries & Helpful Tips to Prevent it

Written by Michael J. Musacchio, Jr., M.D.

Nearly everyone will have back pain at some point in their lives. For most, it will only be occasional, and for others, it can be disruptive to everyday living. As a neurosurgeon specializing in minimally invasive treatments for the spine at Center for Spine Care, I see many patients with back pain that has developed as a result of one of the following type of injuries:

Types of back injuries:

• Accidental

• Unexpected event triggers injury

• These accidents can jolt the spine

• Muscle strains or spine injury may result

• Non-Accidental

• Due to normal activities

• Prolonged or repetitive activities

• Slouching and poor body mechanics

• Fatigue

There are several things a person can do to help prevent back pain from occurring or re-occurring:

Back injury prevention tips:

• Lose weight, exercise, eat healthy

• Stop smoking

• Stretch daily

• Improve posture and body mechanics

• Improve workplace ergonomics

Often times, incorporating these tips into your daily life can alleviate a back injury from progressing. If it continues, it may be time to see a spine specialist.

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Michael J. Musacchio, Jr., M.D., is a Center for Spine Care minimally invasive neurosurgeon specializing in the spine.

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To learn more about Center for Spine Care, visit our website!

D Magazine Medical Directory “Ask the Experts”: The doctors at CSC have answers

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In the recent D Magazine Medical Directory, the Center for Spine Care physicians were prominently interviewed for the “Ask The Experts” section on Spine Health.

Q: What does minimally-invasive spine surgery really entail?

A: Minimally invasive spine surgery is used loosely and means different things to different people. The major difference in minimally invasive spine surgery is that it does not interrupt the nerve or blood supply to normal tissue. Rather, it confines treatment to the pain source or pathology and is performed with small incisions with minimal blood loss so patients quickly recover. In addition, minimally invasive spine surgery needs to be safe, utilizing small, effective tools to enter the spine with anatomic visualization. True minimally-invasive spine surgery requires extensive surgical expertise, experience, training, and is accompanied by a steep learning curve. It requires constant diligence, training and updating of skills. It is the entire approach of accurate diagnosis, specific treatment options, precision surgery, and spine directed rehabilitation that make minimally invasive spine surgery work. Without all elements working complementary, it is not minimally invasive surgery.

“Beware of someone who has taken a weekend course on this,” says John Peloza, M.D. “Minimally invasive spine surgery requires years of extensive training and vigilant refining of techniques to perform this safely without complications. This is for dedicated spine specialists who train their entire careers to get to this point.”

Q: Is evidence-based medicine or clinical research important?

A: Evidence-based medicine is a systematic approach using the scientific method to determine which treatments work best for specific conditions. There is a specific methodology to not only prove the treatment works or does not work, but also to grade the quality of the studies. Evidence-based medicine is essential to clinical decisionmaking. One needs to understand the scientific method, statistical analysis, and significant clinical experience in order to make evidence-based medicine accurate and useful. In our practice, we have been involved in evidence-based medicine for years as part of FDA trials as well as research groups. We also contribute to large outcome databases and have tracked our own outcome data for all of our surgical procedures. Because we know our outcome data, we can help patients make informed decisions and understand the value (outcome and costs) of their care.

Because of the valuable clinical data that we have collected for years regarding our minimally invasive technologies, we are able to offer patients options and predictably successful outcomes.

“At CSC, we specialize in identifying the source of pain and treating it conservatively,” says Nathan Walters, M.D. “Usually, our patients get better with conservative care and need nothing else. Conservative therapy may include a variety of things, from physical therapy to injections or medications.”

The Center for Spine Care (CSC) has been on the true forefront of spine medicine since 1996 by being pioneers of true minimally invasive surgical technologies and by utilizing comparative effectiveness research. CSC collects clinical research data on all of its treatments and procedures, and therefore is able to diagnose and offer patients options based on this research.

“We use the latest, modern technologies such as Intraoperative 3-D Image scans and small instrumentation. The tools are in perfect position so we can perform minimally invasive surgery while looking at a screen,” says Michael J. Musacchio, Jr., M.D. “This enables us to perform spine surgery with incredibly small exposures and increased accuracy, making the surgery safer and the patient recovery minimal. In very rare instances do we have to open the spine anymore during surgery.”

John Peloza, M.D., is a minimally invasive spine surgeon, and medical director of the Center for Spine Care. Dr. Peloza has pioneered some of the most modern techniques currently on the market.

Michael Musacchio, Jr., M.D., is a neurosurgeon specializing in minimally invasive spine surgery.

Nathan Walters, M.D., is director of pain management and specializes in conservative treatments.

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To learn more about Center for Spine Care, visit our website!