In Treating Spine Issues, Less Can Be More


When it comes to chronic neck and back pain, surgery is sometimes the best option. But it should be the last option, say James E. Showery, MD, and Cody Tillinghast, MD, assistant professors in the Department of Orthopedic Surgery at McGovern Medical School at UTHealth Houston and affiliated surgeons at Memorial Hermann | Rockets Orthopedic Hospital.

Neck and back pain are among the most common medical complaints in the U.S., and together they are a leading cause of lost work days. Roughly 16 million Americans — 8 percent of all adults — experience persistent or chronic back pain that limits their everyday activities, according to Georgetown University’s Health Policy Institute.

While spine-related pain can be debilitating, however, it doesn’t always require major surgery.
“I’m a very conservative spine surgeon,” says Dr. Tillinghast. “I prefer for patients to get better without surgery. Spine surgery can be painful, with a lengthy recovery, and it has major risks. When you’re working around the spinal cord, small complications can have lasting effects.”

The first step in treatment is to pinpoint the root cause of the pain, although that’s not always easy. Some spine problems are caused by accidents and injuries, while others stem from issues like herniated discs, spinal stenosis and arthritis. “We also commonly treat cervical myelopathy, a type of spinal cord dysfunction where patients progressively lose function in their hands and develop balance issues,” says Dr. Showery.

Both surgeons start with the least invasive treatment options. “That can involve working with physical therapists to treat the problem and develop strategies to prevent symptoms from recurring. Sometimes this means prescribing some medications to help begin the rehabilitation process and sometimes it’s getting patients referred to the appropriate pain management doctor who can use targeted treatments to reduce pain and symptoms,” says Dr. Showery. “I see myself as the quarterback for their care.”

That can be a surprise for patients, who assume spine surgeons will automatically advocate for surgery. But the treatment model at Memorial Hermann | Rockets Orthopedic Hospital is a multidisciplinary team approach that involves therapists, pain management specialists and clinicians from multiple fields.

“The ability of physical therapists in particular to be a part of that workup process is a huge benefit for patients,” says Dr. Tillinghast. “They get to spend more time with patients during their visits and see how they are doing functionally. One of my patients was referred by a PT who noticed he had an abnormal gait, with worsening balance problems and abnormal reflexes. I saw the patient in clinic the very next day and our workup found severe pressure on the spinal cord that needed surgery. It was a wonderful example of our multidisciplinary approach in action.”

When surgery is necessary, there are ways to minimize pain and reduce recovery times. “Dr. Showery and I try to identify the smallest surgery that will provide lasting benefit. We also both have a real interest in pain control perioperatively, using a combination of local anesthetics, analgesics and other muscle-sparing techniques to hopefully minimize pain afterward,” says Dr. Tillinghast.

“Surgery is usually most effective when used as a treatment of last resort. If patients have already tried other options and had no meaningful relief, then they’re better prepared to deal with the surgical process and the lengthy recovery. And when I do offer surgery, I’m a big proponent of motion-preserving procedures. I try to avoid fusing the spine unless it’s absolutely necessary,” says Dr. Showery.

But both surgeons consider it a success if they can keep their patients out of the operating room altogether. “Our approach is to modify what you can and see if that helps first,” says Dr. Tillinghast. “I had a patient in clinic and looked at his imaging — he had a severely warped spine with multilevel pathology. I’m thinking, ‘This is going to be a 12-hour surgery.’ But when I met the patient, he said he didn’t have any back or leg pain. He did yoga and rode his bike every day, and that low-impact, core-focused exercise kept his symptoms under control. I was imagining this major surgery, but if you don’t have any symptoms, we don’t have to do surgery. That’s the end goal: manage symptoms and reduce pain so you can live your life.”

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