Ask the Doctors Februaury 2007 Issue

Ask The Doctors 02/07

In 1999, I had back surgery to correct degeneration of my spine. Discs were fused and metal hardware was inserted. Within two months I began to tilt noticeably. My surgeon suggested I needed another operation. In seeking a second opinion, I was told that the first fusion was not long enough. Iím now 80 years old and I'm not eager for more surgery. Have there been any new developments that would make corrective surgery simpler or less invasive?

A number of new techniques and instruments have been developed to make spinal fusion less traumatic.

Endoscopic fusion is a minimally invasive form of spinal fusion in which an endoscope is inserted through a small incision. A camera positioned at the end of a cable magnifies, illuminates, and projects the area of surgery onto a television screen. This allows the surgeon to perform the fusion through several small incisions instead of one large incision. This preserves healthy muscle and soft tissue and results in less scarring, less pain after surgery, and a quicker recovery time.

Instead of a bone graft taken from the patientís hip, bone morphogenetic protein (BMP-2) often can be used to speed healing of the fusion. Smaller screws and plates also are now available to hold the bones in place.

Whether any of these new techniques are appropriate for you will have to be decided after a careful evaluation of your situation and discussion with your doctor.

I'm 75 and have scoliosis in my upper and lower spine. I use a walker and canít stand without support. Is there a brace or device that would help support my spine?

While a brace cannot correct the curvature of your spine, custom-molded braces are available that may be able to help support your spine and make the activities of daily living easier for you. Modern braces are made of lightweight plastics and foam materials. These braces are removable and are designed for comfort. You should discuss with your doctor a referral to a certified orthotist who is familiar with spinal braces.

What is the significance of "rheumatoid nodules?" I have a growing nodule on the outer surface of my left arm. Two doctors have told me they are rheumatoid nodules, but another says they are benign tumors of the tendon sheath. They are becoming unsightly, but I donít want to go under anesthesia to have them removed. If they are RA nodules, could they appear in any other areas of the body?

Rheumatoid nodules are painless, though occasionally tender, lumps that appear beneath the skin. These nodules may move easily when touched or they may be fixed to deeper tissues, characteristics that also are present with a ganglion or benign tendon sheath tumor.

Rheumatoid nodules occur in the setting of rheumatoid arthritis, which almost always causes inflammation, swelling, and stiffness in the small joints of the hands and wrists. Determining the correct diagnosis requires that you be evaluated for rheumatoid arthritis with appropriate imaging studies and laboratory tests.

About 25 percent of people with rheumatoid arthritis develop rheumatoid nodules. They are most common on the underside of the forearm and on the elbow, but can occur on other parts of the body. Steroid injections may reduce the size of the nodule.

Surgical removal is an option, but nodules tend to reoccur in as little as a few months when they are present over an area of repeated trauma. The first priority is to establish a diagnosis so that treatment of the underlying cause rheumatoid arthritis can be started.