Golfers Play Same or BETTER After Spinal Fusion
While you won’t want to undergo surgery just to improve your golf swing, new research from Midwest Orthopaedics at Rush (MOR) has filled a void in the golf-related spine literature. Dr. Frank Phillips, Section Head of Minimally Invasive Spine Surgery and Professor of Orthopaedic Surgery at Rush, tells OTW about the first study examining outcomes of lumbar fusion in golfers. “There is no data in the literature that discusses golf and spine fusion surgery; there is no clinical data at all regarding return to play. And yet patients commonly ask their surgeon, ‘When am I going to be back on the golf course?’
“My colleagues and I examined data from one and two-level lumbar fusions I performed over a two year period. Our goals were to determine the ability of golfers to return to play and to find out what factors might predict their return to golf. Patients completed questionnaires asking if they had played golf before or after surgery, and inquiring about the factors that led them to decide to undergo the procedure, what limited them in terms of swing before surgery, when they returned to practice, etc.”
“A full 75% of golfers will be able to play the same amount or more following fusion surgery. Within a year after surgery, 65% of patients had returned to practice and 52% had resumed on course play. Of those who did not return to the sport, 31% attributed it to ongoing back or leg pain. Pre-operatively, 80% of participants said that lumbar pain affected them while playing golf; 50% said that their inability to play golf was a reason they considered surgery.”
“We found that 80% of golfers maintained or improved their handicap post-operatively. After surgery, 50% of golfers stated their distance was negatively affected; 23% indicated that their consistency decreased; only 9% said that their accuracy diminished. It is great to have this data because much of the public believes that if you have a lumbar fusion then you will not be able to move well or have the same swing as you did before surgery.”
“The real question for me is, ‘How minimally invasive spine (MIS) fusion will affect these outcomes?’ At this point, 95% of my one- and two-level fusion surgeries are MIS. I plan to undertake a prospective study to study how quickly and effectively golfers return to play after MIS fusion surgery. My suspicion is that the reduced collateral tissue damage with MIS surgery would expedite return to golf.
Multidirectional Instability of the Shoulder: OK to Consider Surgery
Peter J. Millett, M.D., M.Sc., director of Shoulder Surgery at The Steadman Clinic in Vail, Colorado, was seeing an influx of athletes who had developed multidirectional instability (MDI) of the shoulder. Recognizing the need to find options for patients, Dr. Millett and his research team got to work. He told OTW, “This is a relatively uncommon condition but it is quite debilitating. Modern arthroscopic techniques give us an advantage over older open surgical techniques in that we can address the static stabilizers in both the front and back of the shoulder, the top of the shoulder, and in the rotator interval region all with a minimally-invasive approach.”
“In our study, using arthroscopic surgery for (MDI) showed excellent results with low revision rates and improved patient-derived outcome scores. Modern surgical techniques that use minimally-invasive arthroscopic surgery result in better outcomes than non-surgical treatment and older surgical treatments. Improvement in outcomes was more predictable and more reliable for those who had a traumatic onset to their instability as opposed to an atraumatic onset, but those with an atraumatic onset (i.e., no injury—just occurred) still had significant improvement from surgery. In addition, return to play was high in all subjects but was more likely in athletes whose MDI was traumatic in onset versus atraumatic in onset.
“While the first-line treatment of MDI is typically non-operative with a course of supervised physical therapy, sometimes this is unsuccessful and patients remain disabled from their shoulder instability. From this study, we now know that arthroscopic surgery can be an effective and safe treatment method for these patients, decreasing pain, restoring function, and getting them back to sports and other important activities of life.”
“We were surprised by the efficacy of the procedure and the reliability of the results. We expected those with an atraumatic onset to do a little worse and that is what the data showed, although the vast majority still had very significant functional improvements.”
Asked about the challenges involved with the study, Dr. Millett told OTW, “Getting a pure group to study. We see many patients with complex instability problems but most have other confounding variables such as prior surgery or different type of instability patterns. So getting a ‘pure’ group of patients with MDI, with strict inclusion criteria and minimum of two years’ follow up, with high enough numbers to actually study, and only including subjects who had not had prior surgery was challenging.”
“From this study we have learned that surgery for MDI of the shoulder, which historically has been more difficult to treat, is safe and effective when performed using modern arthroscopic techniques. We hope that in the near future with better patient selection and continued improvements in surgical techniques that we can get even better outcomes and shorten recovery times further for athletes and other patients who suffer from multidirectional instability of the shoulder.”
“I would like to acknowledge the other members of the research team: M. Brett Raynor, M.D., Marilee Horan, Susan Sabido, and Kristin Mapstone.”
ISSG: The Growing Leader in Spine Research
With 14 sites in the U.S. and roughly 90 projects per year, the International Spine Study Group (ISSG) is doing much to advance the treatment of spinal deformity. Shay Bess, M.D. is an orthopedic surgeon with Rocky Mountain Scoliosis and Spine and president of the ISSG foundation, a multi-center nonprofit research foundation. He told OTW, “We focus on conducting multicenter research on outcomes and methodologies to improve surgical care, non-operative treatment, and the evaluation of patients with adult spinal deformities. And while we are proud of the 580 abstracts presented since 2007, what has made our group exceptional is the tremendous camaraderie that allows for productive research synergies. I am continually impressed with not only how smart our members are, but how willing they are to share knowledge and collaborate on projects.”
“We are seeing a gradual shift in terms of integrating what we learn in the research arena. Instead of focusing solely on generating research, we want to know how practice patterns are changing. We are examining specific deformities and tracking how current treatments differ from what was being done five years ago. And while there are always surgeon-related factors as to how patients are treated, we want to discover how our research influences patient treatment to maximize our impact and improve outcomes.”
“For example, we are meticulous about tracking complications and proximal junctional kyphosis (PJK) is a common, and potentially devastating post-operative complication. Our research on PJK has led us to discover that patients don’t need quite as much correction in the sagittal plane as was previously thought. Actually, each patient needs individualized correction based on age, bone quality, and physiology. We are learning that if the patient is rather frail then they will not tolerate much correction and the risk benefit ratio resides on the side of great risk with limited benefit beyond a certain amount of correction. In the past we ‘aimed high, ’ but often the patient could not maintain the correction. You must have a balance between what is ’optimal alignment’ and what is tolerable for the patient.”
“The ISSG is also improving upon the collection of health-related quality of life measures by asking increasingly smarter questions. We are working to integrate patient evaluation metrics that are interactive, such as computer adaptive testing to increase accuracy. Our goal is to discover how to better capture patient desires and patient reported outcomes. We are also investigating how we can partner with other research entities to develop predictive algorithms to determine which patients will have good outcomes.”
“We want to not only provide parameters to guide treatment, but also develop metrics that most accurately evaluate patients. A patient comes to a physician with the primary reason of why he or she is in pain; much of our research on causes of pain in adult spinal deformity has helped physicians provide answers for patients as to why they are likely in pain. We hope to continue to provide resources to health care providers and researcher to improve the evaluation and outcomes for patients with adult spinal deformity.”
dec 5 2018 had l-4,l-5, and sacrum fused. First time no pain in 4 years. I am a 8 handicapper and would like your opinion when I should attempt a comeback and the chances of returning to a good enjoyable golf game. Thanks