Getting Back to Grandpa: Improving Quality of Life for Spinal Revision Patients

Greg and Tricia Pierce enjoy filling their days with gardening, grandkids, building a new home in Blackfoot, Idaho, and taking shifts serving patrons at their area religious temple. But it wasn't always like this. Just a few months ago, Greg could barely walk or stand upright without excruciating pain in his back, hips, and legs.

After a long career managing freight and supply for a local grocery business, Greg suffered chronic back strain and underwent compounding surgeries as his condition got worse.

After multiple procedures to fuse vertebrae in stages over a 20-year span, Greg underwent a large-scale operation in October 2019. This operation fused vertebrae in his mid-back all the way to his pelvis. The surgery seemed to go as planned, but at Greg's six-week check-up, he was nearly bent in half at the waist and unable to raise himself to full height. After a second revision surgery was not successful, Greg's local physician knew it was time to contact advanced spinal care specialists at University of Utah Health's Department of Neurosurgery.

Greg's condition was so severe he had to be flown to Salt Lake City by helicopter.

"When I first met Greg, he was in pain, discouraged, and unsure what to expect from another surgery," recalls Dr. Marcus Mazur, a top surgeon focused on complex spine disorders at U of U Health. "We needed to help him feel relief and restore his quality of life."

Greg had developed an acquired deformity as a result of his previous operations. Each procedure treated only a short segment of the spine at a time, creating a domino effect as his discs and joints above and below those segments absorbed more wear and tear. In turn, these adjacent spinal segments degenerated, causing back pain and nerve compression that also required repair. The accumulation of multiple surgeries can alter spinal alignment and mechanics. As in Greg's case, patients are also at risk for developing an intolerance for standing or walking.

As Dr. Mazur and his care team examined Greg's x-rays, MRI, and CT scans, they confirmed that Greg's current spinal fusion construct was out of place. According to Dr. Mazur, Greg had developed a flat back deformity. This loss of normal curvature in the lumbar spine caused Greg to bend his knees and tilt his pelvis to keep himself from bending too far forward. Over time, patients like Greg find it nearly impossible to stand up straight due to the large amount of energy they expend compensating for their spinal deformity. Correcting this problem would require an extensive revision.

"We needed to restore the curvature in Greg's lumbar spine to improve his standing alignment," Dr. Mazur explains. "As deformity surgeons, we try to pay attention to global spinal alignment instead of focusing on singular levels. Our goal was to correct the lumbar spine in such a way that his head would be in a better position relative to his hips."

After reviewing their findings with Greg and Tricia, a reconstructive surgery was planned for the following week.

"Ideally, we would wait several weeks for patients to recover before performing large-scale back-to-back operations," Dr. Mazur continues. "But he'd tolerated the previous operation well, and we knew he would require an extensive revision, so we moved quickly because all instrumentation had been recently placed. If we acted before scar tissue developed, overall operating time and blood loss could be decreased."

Greg was given time to recover and then carefully monitored to ensure he would be ready for another surgery. Just eight days after his initial meeting with Dr. Mazur, Greg was wheeled into the operating room. But shortly after surgery began, Greg's eagle-eyed team noticed a new problem.

Greg had unexpectedly developed a concerning heart arrhythmia that required a pacemaker to correct. Greg's surgical crew swiftly installed temporary rods to stabilize his spine and moved Greg to the intensive care unit to recover and come up with a new plan of action.

"We have a huge advantage in working here at University of Utah Hospital," Dr. Mazur says. "We immediately coordinated care for Greg within our physician group of anesthesiologists, cardiologists, and intensivists. Our team worked together to rapidly and effectively respond to several issues and provide the best outcome."

Thanks to this comprehensive approach, Greg received his pacemaker on November 19th and returned to the operating room a third time the next day to complete his planned spinal revision surgery.

Dr. Mazur successfully performed a large-scale correction on Greg's spine. This included making a triangular wedge-shaped cut into his L3 vertebra, known as a pedicle subtraction osteotomy. Dr, Mazur was able to create more curvature in the lumbar spine, giving Greg a more natural, upright stance. Dr. Mazur placed additional screws and rods to increase the rigidity of the construct and bone graft material so Greg's spine would fuse in this position.

After this surgery, Greg underwent an extensive recuperation. His body had experienced a tremendous amount of strain and had become deconditioned after weeks of hospital bed rest and years of misalignment. To help his muscles gain strength and adjust to his new spinal positioning, Greg worked through three hours of physical and occupational therapy each day for a month in an in-patient rehabilitation facility after his procedure.

When he returned to the clinic for a follow-up visit at the end of January 2020, his recovery was substantial. With the help of a walker, he was able to walk and stand fully upright.

For Greg, the best part of his healing was being able to return to full social and church activity.

"The first Sunday I was able to go back to church, nobody could believe it when I walked through the door," Greg laughs. "Everyone who sees me now is just blown away. The physical therapy and hospital were just awesome. I got treated so well. It took a lot of work to get everything to pan out, but it was worth it."

"When I got to Dr. Mazur, I could barely stand up," he continues. "Now [my back] is so straight and so exact. I heard that Dr. Mazur was pretty creative—I was glad he had some tricks I hadn't seen before."

For all Dr. Mazur's magic in the operating room, he does his best to set realistic expectations for patients considering spinal surgery. These procedures can have a wide range of outcomes, and surgery may not be successful at treating all types of back pain.

"These are major operations that require several months of recovery," Dr. Mazur says. "For patients with adult spinal deformities, the data show that, on average, 50% experience improvement in back pain on a population level. But individual patient outcomes are difficult to predict. Surgery is more effective for treating leg symptoms that arise from a compressed nerve due to a herniated disc, arthritis, or other spinal deformity."

"For Greg, in addition to back pain, he also had a significant amount of thigh pain and leg weakness," Dr. Mazur says. "One of our goals in surgery was to decompress the regions where there was symptomatic stenosis (pressure). Identifying and treating the appropriate pain generators were essential to him having such a positive outcome."

Months later, Greg continues to see results. Doctors will continue to monitor Greg for several years as his recovery progresses.

"He's always had a positive attitude and been a wonderful husband, father, and grandpa," says Greg's wife, Tricia. "But now he can keep being positive and get on with life."

"After 20 years of dealing with back pain, I don't know if he expected to see as much improvement as he has," Dr. Mazur says. "But he's had a very good outcome. He felt defeated before the surgery. I'm glad he feels some relief now."