SPINE SURGERY AND REHABILITATION
Marlene is a 56-year-old woman who underwent disc replacement and spinal fusion surgery, as well as hip replacement surgery. She was evaluated and operated on by James. M. Loddengaard, MD of Coastal Ortho Advanced Orthopedics.
Marlene was kind enough to share the details about her experience. In a separate article, Dr. Loddengaard comments about Marlene's case and other types of hip and joint issues. Read on for the full story.
All parts of Marlene's story are anecdotal and not meant to be taken as medical advice. See a doctor if you have any questions or concerns about your health.
Tell us about your family and your lifestyle.
I have been pretty active most of my life and I am a registered nurse, which keeps me really busy. I live in Palos Verdes with my husband, who is also very active. We have two grown children and a 2-year-old granddaughter.
What physical activities are you most passionate about?
My husband and I travel a lot, and we love to golf together wherever we are. On trips we do a lot of adventurous stuff too, like bungee jumping, zip lining, and water sports. We'll hike and canoe and go fishing—we're hardly ever sitting down. In the summer we love to ride bikes right along the Strand from Palos Verdes to Venice. I work 10-12 hours a day but can still squeeze in yoga or Pilates at home with that schedule. I also have a treadmill and a stationary bike at home. We live in a hilly area, so it's easy to get a workout walking and biking in our neighborhood. It was during a bike ride that my injury happened.
How exactly did you get injured?
I jumped on my bicycle to start a downhill ride. I adjusted my helmet but had picked up so much speed that my bike got a little bit shaky. To slow down I grabbed the brake but hit the front brake instead of the back brake. I was going so fast that I flipped over the top of my bike and landed on my left shoulder.
How much damage did your bike accident do?
Paramedics took me to the hospital, where the doctors examined only what hurt at that time. They didn't do a full-body examination. I couldn't breathe right afterward, so they found right away that I'd broken three ribs. The impact of hitting the ground as hard as I did going downhill caused a lot of injuries that surfaced a little bit later as well. I had a broken ankle, but I walked on it for about four days before I realized it was fractured. A few weeks later the tendinitis in my shoulder started bothering me, and I realized that I had a slight dislocation or something in my shoulder. My hip was so damaged that I couldn't walk on it, so about two weeks after the accident I went to a doctor I'd seen before.
Was this doctor able to help you?
He tried to drill a hole through my hip to see if he could encourage more blood flow to the area. There was nerve damage from the bones being too close together and not having enough fluid in the joint. After that drilling surgery I saw chiropractors once or twice a week for about a year and a half. I did physical therapy for a year, but no matter what, I couldn't get any pain relief in that hip. It felt like it was broken, and I couldn't walk on it. On days that I felt good I tried to stand up and walk around to get my normal chores done. I took a lot of medication and tried acupuncture, too.
Is that when you found Dr. Loddengaard?
Yes. I had done everything I could think of by the time my friend referred me to Dr. Loddengaard. My friend's daughter-in-law was on her knees, unable to walk, with spinal pain when she was referred to Dr. Loddengaard. After her miraculous recovery, my friend said I had to call Dr. Loddengaard, that he could do something for me. From my first appointment I felt complete confidence in him.
What was so special about Dr. Loddengaard that made you feel so confident in him?
He walked in the room and instead of getting right on his computer he actually shook my hand, and we talked for a few minutes. He wanted to know more about me. He spoke clearly, he had a lot of compassion, he had good energy, and he was on top of all the latest progress in his field. He said there were some new techniques he had performed with good results and that he thought I would be a good candidate for them, too. I wasn't in the dark about what was going on with my body…I had researched enough to understand that Dr. Loddengaard knew what he was talking about.
He said if I wanted to I could talk to other patients with similar situations. Until then, I hadn't met any doctors who wanted me to be as completely comfortable as he did with my decisions. Usually they just say they can do something and you can sign up if you want to—if not, goodbye, see you later. Dr. Loddengaard and I had a longer office visit than what I expected because we talked about my family, what I do, and what my daily tasks are. He wanted to know more about me than any other doctor I know.
What about his staff?
The office staff was well functioning and his assistants were wonderful. You go in and they know what's going on. You get your x-rays before the doctor even comes to see you and they have everything pinned up on the wall for him. Because everything is done beforehand, he has had time to go over it, he has a plan, and he has options in mind for you. He is right on target with his care, a really wonderful caregiver.
Did you know you were going to have surgery by the time you saw Dr. Loddengaard?
Did you see other doctors before Dr. Loddengaard?
I was worried because I went to a different doctor who said that he just wanted to go ahead with surgery. He said my case was a piece of cake and he could do it on his lunch hour, and I would be good to go forever and wouldn't have any problems from that point on.
He scared me and I kind of ran out of his office because I know people half my age who are on full disability from having the procedure that doctor recommended. About three years passed before I actually had my surgery because I had been so worried about the life-long complications and excruciating pain I'd heard about. But after I talked to Dr. Loddengaard, I knew he had better options for me. Two weeks later Dr. Loddengaard performed the surgery. There were no complications.
How was your recovery?
The day of surgery I got up and walked around without any pain whatsoever. I was zooming around the floor of the hospital with no stress, no pain. I wasn't crying for medicine or anything, which was just amazing. Physical therapy went very well. In fact, immediately after surgery my therapist said I didn't even look like I had surgery. I was doing that well.
How long after spine surgery did you have your hip replacement?
It was only a few weeks later. It scared me to death to have a full hip replacement because as a nurse I'd seen a lot of elderly people have problems with the procedure. But I had also seen plenty of good results, and I knew that my age and good health made it likely that I'd also have good results. After I decided to have the surgery, I felt totally comfortable because Dr. Loddengaard had been such an amazing spine doctor. I knew I was in good hands. Ten days later I went back to work for light duty. My physical therapy changed a bit to focus on both my hip and spine, and I progressed without any problems.
What was your total recovery time, from the spine surgery, through the hip surgery, and to normal life with no physical therapy?
One month. I did give up the serious trauma nursing, which was really intense physical labor, and went into ambulatory care. It's still long shifts but not as fast-paced and physical.
It's been three years since your surgeries. How are you now?
I've been great ever since. My husband and I just got back from a trip where we did some bungee jumping, zip lining, banana boating, hiking, and everything we possibly could, and I had no problems. We played an 18-hole golf course that required climbing, not just riding around in carts, and I had a great time doing that, too.
What advice would you give people who are in pain after sustaining an injury or because of a condition?
I think they should do something right away. Really open the door to getting yourself corrected quickly. The time that I waited I could regret, but I don't want to have any regrets. I did learn a lot by reading along the way. I stayed away from the internet because there is way too much information and way too much distraction. Instead I went to a medical library, where I read about hips, spines, and got some local information. There are support groups everywhere. You can speak to people who have had hip surgeries and spine surgeries. Make sure your plan is all-inclusive: start with the doctor and then go all the way through physical therapy.
Why would you recommend Dr. Loddengaard to other people?
Dr. Loddengaard is worth the time. He is kind, intelligent, and compassionate about what he does and what he will do. I feel so confident knowing that no matter who I refer to him, and I've sent referrals to him already, that he will do the very best for them that he can possibly do, and if he cannot he will make sure they are in good hands. He is that compassionate that he will not take on a case unless he knows exactly what is going on and that he can make a difference. He finds the very best for you.
Finding a physician, getting the very best recommendations, interviewing them, and feeling comfortable with them is very important. If you feel good with them then that is the doctor to stay with. If you feel you haven't found the right doctor, you need to keep researching until you do.
JAMES M LODDENGAARD, MD
MARLENE’S SPINE SURGERIES AND HIP REPLACEMENT
James M. Loddengaard, MD has been an orthopedic surgeon since 1983. He specializes in spine surgery, joint replacement, and knee and shoulder arthroscopy. He is board certified.
Below Dr. Loddengaard discusses the spinal fusion surgery and hip replacement surgery of Marlene, one of his patients. Click here to read Marlene's interview. He also talks about what patients can expect from their doctor if they're considering treatment for back pain, whether it's related to a herniated disc or other cause, or treatment for any knee, hip, or shoulder joint issues.
Why are you passionate about being an orthopedic surgeon?
It's wonderful to be able to fix things and make people better. It's extremely gratifying and because people are so different, it's interesting. I went to Cal Tech for my undergraduate degree. There wasn't a single multiple-choice test. The whole education was based on problem solving. Because of that my patients benefit from my ability to investigate their problems with a fresh perspective. Real life isn't a multiple-choice test.
What helps you relate better to your patients?
I've had my share of shoulder and knee injuries and surgeries. I had to recover from those, so I understand what the process is. When someone comes to me in pain, I know what I would feel like in that situation. Everybody is very different, though. I can't look at myself and assume everybody else is going to be the same. Some of my patients are fearful and cautious, while some are just eager to return to normal life as quickly as possible. People have a wide range of responses to pain and injury. I look at each patient and try to understand who they are and what their limitations and strengths are.
What did you think when you first met Marlene and heard about her problems?
Marlene had been in a terrible bicycling accident about a year before and had sustained several injuries. By the time she saw me, her spine and hip problems were big and disabling. She had spondylolisthesis, a condition where a spinal disc is not lined up properly. This was pinching a nerve and causing a lot of pain, which was radiating down her leg. Marlene's hip had also been injured in her accident. She had a dead femoral head, the "ball" of the hip's ball and socket. Bone is full of blood and her hip bone hadn't gotten enough of it, so it died. She had already pursued physical therapy, chiropractic care, medication, and just about everything else she could think of prior to seeing me. It was clear that those smaller measures were not helping her anymore and that she needed surgery.
How was her recovery?
Marlene was and still is a get-up-and-go kind of person. She had no post-op pain, did her physical therapy, and was fine in a month. She's had no complications, and that's not uncommon in active, healthy people, even those much older than she is. She was 51 years old when she came to see me, and it's been three years.
Why do you think Marlene is such a success story?
She is motivated and energetic. She is a strong person and optimistic, not fearful. She is athletic and not overweight. As her surgeon I gave her a chance, and she took the ball and ran with it.
Is Marlene's type of success common?
There is a range of results, but success is high among those who have similar procedures as Marlene. About 90% of people who have degenerative spondylolisthesis and stenosis repaired surgically recover very well. About 90% of people who have a total hip replacement also recover very well. That's a high number of patients who are happy with their outcomes. Marlene has no symptoms at all, so obviously she has done extremely well, but she is certainly not the only one who has done quite well.
When a patient comes to you with pain, where do you start?
First I see what sort of treatment they've had, how disabled they are, and look at their MRI and x-ray findings. Some of my patients are not ready to sign up for surgery, some will do anything they can to avoid it, while others don't want to fool around with ineffective treatments or hopeful ones that are not that likely to help them. I'm not an autocrat—I work with people and see how they want to proceed.
Do a lot of people live with their pain longer than necessary?
Most people I see have a reasonable tolerance for pain and come to see me when they can't manage it themselves anymore. There are some patients that do wait until their problem is more difficult to treat.
It seems difficult to determine when to seek an orthopedic surgeon for back pain. There are so many other practitioners and options out there. How do people know whether you're the best doctor to see?
Anyone with severe pain down their leg, weakness, or numbness and whose MRI and x-rays show a pinched nerve is often a good candidate for surgery. The longer a damaged nerve is left untreated, the smaller the chance that it will get better. For example, one of my patients had bad leg pain and weakness in her ankle. There was a one-month delay before she could have surgery, due to some of her other medical issues, and during just that one month, the weakness turned into a full foot drop. She couldn't lift her ankle at all. That's how quickly nerve damage can progress. She's actually doing well now and the nerve seems to be coming back, but I've seen patients that weren't so lucky getting function back because they waited too long. You don't want to let nerves get too squished and damaged because they may not wake up.
Some patients are not good candidates for surgery. I treated one man who had back pain for five years. He had a couple of degenerated discs, no leg pain or pinched nerves, but he is tired of his back pain. His best option was a better living program: exercise, stretching, cardio, and core strength. Not everyone likes the idea of changing their lifestyle, though. Those patients may find a spine surgeon who will perform a fusion or a disc replacement, but the success rate on those patients is not as good as it is for pinched nerves. I've seen patients that had fusions from very aggressive spine surgeons and their back still hurts. Now they have a stiff back and they aren't happy. You can't fix it at that point. So I personally am not a fan of doing fusions for back pain except under very specific circumstances, like in Marlene's.
You see a lot of patients every year. Approximately what percentage of them do you operate on?
I send lots of people to therapy and talk about exercise with them. I perform surgery on somewhere between 5% and 10% of my patients.
What kind of pain should people not ignore?
Pain that gets steadily worse should be evaluated by a doctor.
Should people see an orthopedic surgeon before seeing a physical therapist?
Generally speaking, yes. The issue is how well a physical therapist can diagnose something in comparison to an orthopedic doctor. Therapists have wonderful skills, but they don't take x-rays or MRI's, and without that critical step they may give the wrong diagnosis and treatment.
What do you say to people who are scared of surgery?
I discuss possible complications and the frequency at which they statistically occur. Those numbers give a great perspective to patients. It helps them realize that having surgery gives them a good chance at getting better, even though there are still risks. Then they can make their decision in an educated way, hopefully with less fear.
What treatments do you recommend to patients who are not surgery candidates?
Medication, exercise, therapy, braces…there are a lot of options.
Do you find that those measures just delay surgery, but don't help patients avoid it?
No, there are a lot of conditions that just don't need surgery. They just need time or they need a specific treatment. One of my patients had back pain for years. She was only 20 years old. I sent her to a physical therapist because she had a little scoliosis and a couple of little structural quirks. Two months later she was so happy. Her back felt so much better and she didn't need surgery. There is nothing for me to do for her and that is true of most back problems.
Another condition like that may not need surgery is a torn meniscus in the knee. If playing tennis is a patient's life and they can't do it because their torn meniscus won't let them, I'll fix it. A patient who just wants to walk from here to there, who doesn't want surgery, and has a stable knee can elect not to have surgery.
Some patients follow their rehabilitation instructions very well and some don't. What is the difference in outcomes?
Most conditions won't improve unless the patient follows their rehabilitation. I remember a patient who had a fracture in his leg. After surgery to repair it, he didn't really do his exercises. One year later his thigh was an inch and a half smaller on the operated side. The muscle doesn't just come back automatically.
Exactly how fast does muscle atrophy (weakness and shrinking) happen?
It can start within a week. We can use a CT scan to measure muscle volume on the first day of someone who has become bedridden and by the eighth day the volume is smaller. It's kind of scary-fast. That old cliché, "If you don't use it, you lose it," is very true.
Every recovery is different. Talk about different "normals" you have seen.
Marlene, for instance, is on the fast end of recovery. She bounced back really fast, which is great. There is a certain class of people that seems to be like that.
Another patient, a 75-year-old man, was in his mid-70's and worked out all the time. He had spinal stenosis with leg pains and weakness and wasn't able to walk much. I performed a six-hour, three-level fusion and cleaned out his spine. It was a complicated situation, but he is back to exercising regularly. He has virtually no pain and can walk as far as he wants again. He bounced back amazingly fast because he is a motivated athlete.
An overweight patient in their 50's who hasn't exercised since P.E. in high school is more likely to have a slower recovery. They might take several months before they get to the point where they can walk as much as they want.
It seems like age isn't the primary factor when considering surgery. Is that true?
The issues are what medical conditions a patient has and how does that affect whether they are a good surgery candidate. Someone whose heart condition requires blood thinning medication can't be operated on. It doesn't matter if they are 50 or 75. I've performed about a half dozen spine surgeries on patients over 90, who couldn't get out of bed and had severe pain in their leg. I have done a lot of back surgeries on patients in their 80's. A recent 86-year-old patient who had a partial knee replacement is six weeks post-op and feels great. He's walking around with his cane and his knee is hardly swollen at all.
The oldest joint replacement patient I've treated was 94. She wasn't complaining of pain that much, but her leg was unstable. It was so crooked that it was giving out. After I replaced her knee joint, she recovered slower than average, but she was stable and did wonderfully.
Can smokers have surgery?
I just saw one of my patients who is about 50 years old. He smoked, was overweight, and had back pain for a few years. I gave him the data on smoking: it increases spine degeneration, and smokers have poor outcomes with surgery or physical therapy. They don't bounce back. Smoking interferes with function and recovery because it constricts blood vessels, limiting blood supply. Blood brings all the good healing components to our body parts. I was really excited when he quit smoking and lost weight, and now his back feels better.