A new implant for patients with severe back pain can replace damaged bones in the spine and, unlike traditional surgery, doesn’t restrict movement. Mother-of-two Melissa Ingalls, 47, from North London, had it fitted, as she tells ADRIAN MONTI.
THE PATIENT
Back pain has been a problem for me since I was a teenager. It was mostly a dull ache in my lower back that would come and go, but it got worse over time.
My mother had back pain her whole life too — as a result of osteoarthritis — so it was probably genetic.
A new implant for patients with severe back pain can replace damaged bones in the spine and, unlike traditional surgery, doesn’t restrict movement (stock photo)
I’d see a chiropractor occasionally who’d give me exercises to manipulate my spine which helped a bit.
By 2009, when I was 39, I could no longer stand or sit for any length of time without pain kicking in, which made my former job as an office manager difficult.
I went to see an orthopaedic specialist who gave me scans showing I had osteoarthritis in my spine, meaning the cartilage between my bones had completely worn away, so bone was rubbing on bone — causing pain.
It didn’t come as a surprise but I feared I’d be left in pain for life.
By now it stopped me doing what I enjoyed; I could no longer play golf and even household chores were a struggle.
I was prescribed painkillers and anti-inflammatory drugs, and even had steroid injections directly into my back to reduce the inflammation — but these only eased symptoms temporarily.
My surgeon said my final option was spinal fusion, when the bones on either side of the damaged joint are fused using metal rods and screws.
But it would mean I’d lose full range of movement, so I refused to have it done. I carried on taking anti-inflammatories and did yoga and pilates for pain relief — hoping it wouldn’t get worse.
Sadly it did, and by December 2016, I was getting shooting pains down my legs as well as constant back pain — it was completely debilitating. We were moving around due to my husband Jim’s job, so I wasn’t able to see a specialist until April 2017.
I used my private health insurance to see a spinal surgeon at Highgate Private Hospital in London. I had an MRI on my spine which revealed I not only had worn cartilage in one of the joints, but two small bones in the joint had moved out of place and were pressing on the nerves nearby. He said this was caused by my arthritis and was leading to lower back pain and the shooting pain down my legs.
My options were either to have the joint fused, or he could use a new implant called TOPS.
This implant would fix the bones into the right position but still allow the joint to move. It would stop them rubbing on each other and avoid them touching the nerves too. It would provide long-term pain relief and would give me back some quality of life, so I couldn’t say no.
I had the implant fitted in June under general anaesthetic. The operation took about two-and-a-half hours and I was given painkillers after so didn’t feel too bad.
I stayed in hospital a little longer than normal because a scar from previous surgery was aggravated. Usually patients can walk on the same day but I had to lie flat for two days while the scar healed. Soon I was sitting in a chair and then walking with help from a physiotherapist. I was home after ten days and only took paracetamol occasionally for pain relief.
I can now walk, stand, bend and sleep without any discomfort. I’m optimistic it’ll offer me many pain-free years.
THE SURGEON
Bob Chatterjee is a consultant spinal surgeon at the Royal Free London NHS Foundation Trust and Highgate Private Hospital in London.
About 11 per cent of adults have back pain as a result of malalignment in the back, or spondylolisthesis.
This is where the vertebrae — the small bones of the spine — move out of position. It happens when two bones within a joint slip forwards or backwards, typically as a result of wear and tear or conditions such as osteoarthritis which damage the joints in the spine that enable you to bend and twist.
As the joints become damaged, they lose cushioning cartilage in between the bones. This means that, as well as rubbing on each other — causing pain — the bones can slip away from each other and put pressure on nerves nearby.
Typically it leads to lower back pain and pain shooting down one or both legs. Patients are offered physiotherapy, pain relief or anti-inflammatory drugs to relieve some symptoms but ultimately surgery is the only solution.
The traditional way is by fusing the joint. This involves taking bone from the pelvis and fixing bones around the damaged joint together.
Though this surgery is effective, we are replacing a joint with a rigid bone, so patients are left with limited mobility. This can lead to additional issues over time because extra pressure builds up on the joints above or below the fused part. These adjacent joints may wear out more quickly and make people immobile.
But a new implant realigns the joint while maintaining its flexibility. The 10cm-long TOPS implant has four ‘leg’ attachments made of titanium, which rotate to replicate how a normal spine joint moves. I describe it as looking like a four-legged spider.
We have used it since 2013, but until now the technique has required a large 15cm incision which damages muscle and requires three months’ recovery time. I was keen to use the implant but believed a smaller incision of around 6cm was needed to make it better for patients.
A smaller incision means a reduced infection risk, quicker recovery (a few weeks compared to months), less pain, less muscle injury and a shorter hospital stay — most patients can leave after a few days. Melissa was among the first patients I tried the new technique on.
With the patient under general anaesthetic and lying on their front, I mark where the implant needs to go in the centre of the back above the buttock. I make a 6cm incision here and insert the implant so it sits in the centre of the joint that needs to be fixed. Then I make four tiny incisions in the skin around where the implant is — one incision for each ‘leg’.
I then insert each ‘leg’ one by one and secure it with one screw into the misaligned bone and one into the central part of the implant. This effectively fuses the joint in place but still allows it to move normally. This takes about two-and-a-half hours, an hour less than fusion surgery.
Patients are encouraged to walk the same day, unlike traditional fusion where they can’t walk for two days due to pain. As with fusion, the implant is designed to last a lifetime.
There are currently only a handful of UK surgeons fitting these implants but given the advantages, it marks a move away from fusion as the conventional way to treat many back problems.
TOPS costs £8,000 to the NHS and £12,000-£15,000 privately.
Medical Miscellany
Why do we yawn even after a long night’s sleep?
Yawning is not directly linked to the number of hours of sleep we’ve had, but is an evolutionary response to changes in our alertness.
That’s why we tend to yawn before or after sleep and at times of stress, says Simon Thompson, professor of clinical psychology and neuropsychology at Bournemouth University. A recent theory is that it’s linked to the stress hormone cortisol, which raises the temperature of the brain. ‘Yawning is thought to allow more oxygen into our lungs as this reduces our brain’s temperature,’ explains Dr Thompson.
According to this theory, after a good night’s sleep we yawn because our brain’s temperature is still too high — we release cortisol to wake us up — so we yawn until it falls to a normal level.
Accidental cures
Medicines discovered by accident. This week: Warfarin
For well over half a century, warfarin has been the main blood-thinning drug to treat patients at risk of potentially fatal blood clots — often as a result of a deep vein thrombosis (a clot in small blood vessels in the lower legs).
The anticoagulant was discovered when farmers in poverty-stricken Twenties America were forced to feed cattle damp or mouldy hay and noticed seemingly healthy animals dying from internal bleeding. It turned out that a mould in the hay contained an anticoagulant called dicoumarol.
In 1940, scientists at the University of Wisconsin-Madison isolated the compound, paving the way for mass manufacture of warfarin.
Although it’s widely used in humans, it also gained notoriety as a deadly rat poison.