After they ask themselves the 3 questions before referring a patient to a spine specialist, your provider may follow through, and when a primary treating physician refers an injured worker to the specialist for diagnostic tests, the worker might suspect that there is surgery ahead. This is not always the case.
In fact, there’s a chance that they might even leave the specialist’s office with a prescription for antidepressants, among other possibly unexpected treatments.
RateFast’s own Dr. John Alchemy and Claire Williams interview orthopedic surgeon Dr. Athanassious about the circumstances surrounding complications with spinal injuries in injured workers, and where the primary treating physician may direct them when more specific care is needed. Click here to listen to the podcast on iTunes.
If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!
Dermatome (noun) – an area of skin that is mainly supplied by a single spinal nerve
Myotome (noun) – the dorsal part of each somite in a vertebrate embryo, giving rise to the skeletal musculature
Magnetic Resonance Imaging (MRI) (noun) – a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body
X Ray (noun) – a photographic or digital image of the internal composition of something, especially a part of the body, produced by X-rays being passed through it and being absorbed to different degrees by different materials
Pathology (noun) – the study of the essential nature of diseases and especially of the structural and functional changes produced by them
Microdiscectomy (noun) – typically performed for a herniated disc, a microdiscectomy relieves the pressure on a spinal nerve root by removing the material causing the pain.
Narrator: Welcome to the California Work Comp Report, a podcast hosted by Arun Croll and Claire Williams, featuring Dr. John Alchemy.
Claire: Hello, and welcome to the California Work Comp Report podcast. Today is April 14th, 2015, and I’m pleased to announce that we have a guest today, along with your host, Dr. John Alchemy. Hello, Dr. Athanassious, and welcome.
Dr. Athanassious: Hello, thank you for having me.
Claire: Yes, thanks for joining us.
Dr. John Alchemy: So, Dr. Athanassious, tell me a little bit, and the listeners, where you did your training as a spine doctor, and how long you’ve been doing these exams.
Dr. Athanassious: I went to medical school in Philadelphia, and I went on and did my residency in New Jersey at Monmouth Medical Center, where they did a high amount of spine surgeries. And then I went on and did a sub-specialty training after completing my orthopedic training, in spine surgery specifically, for management of neck pain, mid-back pain and lower-back pain, at Stanford Medical Center. And there, spent a year focusing on the treatment of back disease, both non-surgical and surgical treatment patterns, and ways of treating pathology and pain related to the back and neck.
Dr. John Alchemy: So in addition to all this training that you’ve done, what additional certifications do you have as well that sets you apart from maybe just the general orthopedist who might treat some primary back pain?
Dr. Athanassious: So I’m a member of the National American Spine Society, the North American Spine Society, I’m a member of the Society for Lateral Access Surgeons, I also have affiliations with the Cervical Spine Society. Those are the certifications that I belong to, and that allows me to offer a more in-depth look and treatment for neck and back diseases.
Dr. John Alchemy: Great.
Claire: And so, as a spine surgeon, what does the typical exam look like? How is it different from a primary treating physician’s exam?
Dr. Athanassious: It’s a little bit different because we look at the exam from an aspect of “What can we treat, is there something that we can fix, is there something that’s objective that I can treat?” But not necessarily from a surgical perspective, but more of something that is a structural cause that I can give an answer to, and we can more reliably predict the outcome for the patient. So that guides the treatment and the physical examination, depending on if the patient comes in with neck pain, mid-back pain or lower back pain, and it is more specific in terms of the evaluation of the motion of those particular areas, and how that motion relates to a patient’s disability, and how the neck pain or lower back pain or mid-thoracic pain, which is the mid-back, is related to the upper or lower extremities. Furthermore, we go into great detail and depth to devise the exam and the extremities, [unintelligible] sensory aspect, a reflex aspect, and also a motor or strength aspect. And we divide those into what we call dermatomes, which is how nerves map throughout the body and give sensation, and myatomes, which is how the nerves connect to different muscles within the body and allow us to give a specific idea of where is the disease or pain coming from, and what nerves specifically in the spine may be related to that pain or that disability.
Claire: Oh, very comprehensive.
Dr. John Alchemy: I have a question for you then. For work comp, people just aren’t showing up at the orthopedic spine expert saying “I lifted a box this afternoon and my back is sore.” So you’re a referral source, you’re the expert. So when a primary treating doctor sends a case to you, why would they be doing that, what kind of treatment may they have received before you get a chance to get your hands on them and talk to them?
Dr. Athanassious: Generally, before people come to see me, especially within the workman comp world, the patient has been seen by a doctor or a nurse practitioner or a physician assistant who has treated their back pain. They have maybe ordered some x-rays, maybe they have given the patient a short course of physical therapy, or a short course of anti-inflammatories, and for one reason or another they feel that the patient needs a more in-depth look and a more broad, well actually, a more specific look, at the reason for the patient’s pain. They may have questions about if the patient is safe to go back to work. Is there further treatment that is necessary? Do I think that they would benefit from a different type of physical therapy or some different type of medication? And that’s the reason that they generally get referred to me.
Dr. John Alchemy: Great, great. So the next question I have after listening to that then, and patients come in all the time saying “I need an MRI,” or “Do I need an MRI?” Can you talk to us a little bit about how you view the MRI as a diagnostic tool and how essential it is to really helping giving an opinion as an expert?
Dr. Athanassious: Okay. The MRI is very helpful, specifically if the patient comes in and has had prolonged back pain for greater than six months, has had x-rays which show possible disease, or even if they have evidence of maybe no disease. Specifically if the patient has [unintelligible], for instance, if they say they have pain that starts in their neck and radiates to their thumb, then we think about something that may be occurring within the neck, possibility at the C5-C6 level. You can see on x-rays, some evidence of that disease but the MRI gives us a very clear, specific look at the nervous structures and the way that the nervous structures are affected. Additionally, if someone comes in with lumbar disease, and say somebody did not have back pain ever before, they bent down and they felt a pop in their back, and slowly over time they just started to develop weakness within their legs. An x-ray would not necessarily show a herniated disc, it would not necessarily show [unintelligible] for the patient’s leg pain, and [when] specific patients develop a deficit, or weakness, an MRI gives us a very specific look at that possibility of disease being from the spine, and possibly from a herniated disc, that would not be evident on x-ray. Especially in a younger individual that does not have disease that’s clearly seen on x-ray. X-ray gives us a good idea of what’s going on in the bones, and generally x-rays require a certain length of time that the disease has progressed before you can see changes on the x-ray. MRI allows us to see the softest tissue structures, including the nerves, the discs and the joints, which an x-ray does not give us as good of a look at.
Dr. John Alchemy: Great.
Claire: And outside of MRI, x-rays, what else do you have to help you decide whether or not someone’s going to benefit from surgery?
Dr. Athanassious: A physical examination is a very important part of the evaluation of the patient. And it’s not only the physical examination in terms of touching the patient and seeing the strength and the range of motion in the back or the lower extremity, the physical examination starts from the moment that I walk in to see the patient. Spine surgery is much different than other types of surgery for instance in orthopedics, such as a knee arthoplasty, which is a total knee [replacement], or a hip arthoplasty. Just because someone has arthritis in their back, it does not mean that they would benefit from a surgical procedure or a fusion. A person needs to have a constellation of symptoms, additionally they need to have a, almost a mindset, an appropriate mindset in which they will be helped from this possibility of surgery. And it’s been shown in multiple studies that if you look at x-rays or MRI’s across the board with a certain level of degenerate disease, different people will experience this pain and this disease in a different way. Pain is a product of disease, somewhere in the spine, for instance, that signal is sent to the brain, and the brain decides how it’s going to interpret that signal. Research has found that, for instance somebody maybe who has a high level of depression will experience more back pain given the same amount of disease on x-ray or MRI than somebody that does not suffer from depression. So, in that case, for instance, it may be more appropriate to yes, treat the patient’s back pain, not by surgical means, but also get that patient help from a different modality, such as seeing a psychologist or psychiatrist for treatment of their depressive disorder.
Dr. Athanassious: So a physical examination starts when a patient walks in the room, and observation of the patient, and listening to the patient’s story specifically, and then moves on to actually looking at the patient’s back, neck and extremities, even the way that they move and they walk. And addressing that with the patient’s story, their main complaint, and what the doctor or surgeon thinks can help them.
Claire: So, with people’s different experiences of pain post-operation, how do you go about determining their functional limitations, especially for something like returning to work?
Dr. Athanassious: Sure. There’s different types of procedures that are done, they can be purely soft tissue procedures such as a microdiscectomy, or such as a procedure to treat spinal stenosis. These are purely soft tissue procedures with some small amount of bony procedure, and theoretically, there should be no destabilization of the spine. So the way for these small [unintelligible] that I look at, the patient’s [unintelligible] to go back to work and their ability to function and go back to the work community, is how far are they out from surgery. And how are they doing in terms of decreasing their requirement for pain medication, and for instance, we know that a patient that has a microdiscectomy should be able to return to work at around the 6-week mark, and even there was research done at Stanford that shows that these patients theoretically could go back to work after a week with no increased risk of reherniation, which is a big fear with a microdiscectomy or removal of some part of the disc. Generally for me, I allow my patients to work themselves down from their pain medication requirement, and allow them to be comfortable doing their activities of daily living, and then I get them back to work, which is generally for most procedures around the 6-week mark. For a fusion procedure, I use, in addition to what I just spoke about, I look at x-rays, I look at how the hardware looks, does fusion appear to be taking place, for instance in the neck or in the lower back, and I usually get them started to partial work and get them back to work around the three-month mark to six-month mark, depending on the procedure. [unintelligible]
Dr. John Alchemy: So you’ve talked about average healing time and getting people back to work and things like that, it’s all really great stuff. I guess the last question I have is, when someone goes to see a spine expert or a back expert, and considering maybe having surgery, what kind of things could you tell our listeners that maybe they should ask of any expert that they’re going to see? What do they really need to know and walk away from that appointment with in their mind? What needs to be answered for them?
Dr. Athanassious: I think some of the important questions that need to be answered before they walk out of, or to make an appropriate decision or to help their own care, is whether the disease that they have, is that clearly understood? The next step is, what treatments are offered? In totality, so not only operative treatment, but they should talk about all non-operative treatment that is also possible. And the next step is, what are the chances that these non-operative or operative treatments are going to improve their symptoms and get them back to where they need to be? I think the understanding of the pathology, the disease, the alternative treatments, and recommended treatments and the chance that there’s going to be improvement after all of these treatments are done needs to be clearly understood.
Claire: Great, well thank you so much for joining us today. It’s been a pleasure to have you on the show. If there are any insurance adjusters or patients interested in contacting you, Dr. Athanassious, how could they go about doing that?
Dr. Athanassious: They can contact our office directly at (707) 546-1922, and they can just ask to speak to my medical assistant, or they can just schedule an appointment to see me. Most of my appointments, the first appointment is 45 minutes and then following appointments, depending on the patient, can be 15 to 30 minutes. Additionally, if they want more information regarding our office or about me, they can go to SRortho.com.
Dr. Athanassious: Correct.
Claire: Well, thank you so much for joining us at the California Work Comp Report, again today is April 14th, 2015. And for more information on California workers’ comp topics, please visit the blog at rate-fast.com. Dr. Alchemy, Dr. Athanassious, thank you.
Dr. Athanassious: Alright, thank you for having me.
Dr. John Alchemy: Thank you.
Narrator: Thank you for joining us for this episode of the California Work Comp Report. We look forward to next week in continuing our discussion of work comp claims in California. Questions or comments? Got a great workers’ compensation story to share? Find us on Twitter at @ratefast or at rate-fast.com.