As COVID-19 swept across the United States in mid-March, hospitals rushed to reprioritize their care focus. Taking an all hands-on deck approach, surgeons were forced to postpone elective procedures to ensure the availability of empty beds for coronavirus-stricken people. This turn of events left back surgery patients in a lurch—their surgeries were indefinitely postponed. Even when elective surgeries are opened up again, it may be several months before your surgery can be rescheduled.
For patients caught in a surgical holding pattern, we asked back and spine surgeons and other health care practitioners how you can endure the wait. Here’s what they had to say.
Many of you may have decided to postpone spine surgery or may have been told that your surgery had to be rescheduled due to the COVID-19 pandemic. Both scenarios present a stressful situation of prolonged pain and anxiety in anticipation of a future—the timing of which is unknown—surgery.
There are a few things to keep in mind while waiting to have your planned surgeries. First and most important, is if you experience new weakness, bowel/bladder dysfunction, or increased pain, please seek immediate medical attention. Weakness or any significant neurological change as well as intractable pain are reasons to proceed urgently with surgery rather than delay the procedure. Being in the hospital following surgery has not been shown to put any patient at an increased risk of acquiring the infection.
For the remainder of you, although you remain in pain, please use this time to work on strengthen your core back and abdominal muscles in preparation for surgery—a forced prehab program while waiting for surgery.
Continued pain management will likely be necessary whether this involves just NSAIDs and muscle relaxers, or something more involved requiring the help of a pain management specialist will depend on the specifics of your condition. Maintain contact with your spine surgeon and take heart that we are all in this together and will get through it together.
Faheem Sandhu MD, PhD Professor of Neurosurgery Director of Spine Surgery Co-Director, Center for Minimally Invasive Spine Surgery MedStar Georgetown University Hospital
For those of us who suffer from back pain or treat people with back pain, we all know the importance of maintaining a regular and consistent schedule of exercise and sleep (and nutrition, but that’s another story).
We are a big believer in the importance of exercise/fitness to treat and manage back pain. Unfortunately, this pandemic crisis makes it difficult for those of us who like their local gym and/or rely on trainers/therapists/buddies to motivate them. Despite these limitations, it is vitally important for us to stay on track with these fitness programs.
To that end, we encourage all BackerNation members to reach out to their providers and explore ways to continue their care through the wonders of the internet. It is amazing how much can be done at home, if you have some simple items and access to knowledgeable people.
As a spine surgeon who’s in Los Angeles, I have had to cancel my elective spine operations in the face of COVID-19. These are the few things I would want my patients to keep in mind:
Some spine operations are considered less elective than other spine operations and may still qualify for having surgery done now rather than being delayed. These operations include a) surgery for spinal cord compression resulting in weakness and poor coordination of the arms and legs, b) surgery for compression of the nerves that are resulting in a dropped foot or bowel/bladder incontinence, and c) tumors or cancers involving the spine. Pain by itself is not considered an indication for urgent surgery.
Stock up: For patients who don’t meet “urgent surgery” criteria, I would recommend that they make sure they have at least a one-month supply, but preferably a 90-day supply, of the medications they are currently using to help ameliorate their symptoms. Do not self-medicate prescription medications and take your medications other than the way it is prescribed by your physician.
Try conservative measures again: For most patients who were about to undergo elective spine operations, they must have failed conservative treatment or conservative treatment did not provide sufficient relief in the past. For instance, physical therapy often does help, but does not provide the type of relief that they would get with surgery. Since surgery is not an option at this time, going back and trying to conservative measures that helped slightly in the past is very reasonable. If your physical therapy center is closed because of COVID-19, there is a wealth of information on YouTube from certified physical therapists to who teach exercises that specifically focus on core strength training.
Stay active and positive: Pain is a multi-faceted disease process. Although there may be structural causes of pain that require surgery, pain is often made worse by depression and/or anxiety. It is critical in this time of social distancing to stay positive and not isolated to the point of depression and anxiety. Keeping a positive mindset is one of the most critical things my patients can do to help survive the wait for spine surgery. If you don’t believe that anything except surgery is going to help, then nothing will. If my patients are able to tolerate doing exercise in any form, I highly recommend it. We know that exercise increases endorphins, which in turn also helps reduce the amount of pain and depression. increases endorphins, which in turn also helps reduce the amount of pain and depression.
Try to eat healthy: Many of the foods that we eat can increase the overall inflammatory state in our body and this inflammation can promote pain. Also, this is a great opportunity to learn to cook healthy and avoid fast food. Even a modest lost in weight can help reduce the strain on the spine and help reduce back pain.
Stop smoking. Yes, smoking does increase your inflammatory state and promote pain. If for none of the other myriad of reasons to stop smoking, do it to reduce your pain.
Feelings of insecurity tend to appear before surgery especially when it gets delayed. One would feel they are not in control of their body and surroundings be it in terms of pain or moods. Thus, getting ready for an operation can involve physical and emotional aspects which can produce positive effects on each of those levels.
Well-informed regarding the surgery. One should receive clear and detailed information regarding the procedure, duration of surgery, and what they should expect post-operation. This will alleviate one’s anxiety and overthinking.
Adequate support group during hospital stays prior to surgery. Family, friends, as well as nurses, can serve as a source of strength and encouragement for the patient. Other external aids can include material comforts, technical help, and other ways of easing the patient’s pain.
Relaxation therapy. In deep breath relaxation, the patient tenses the diaphragm when breathing in and relaxes it when breathing out, with the aim of reducing chest muscle action.
Right now, the world may be on hold, but your mobility, pain, and balance issues are not. The current pandemic of COVID-19 should not interfere with patients’ ability to consult with their physical therapist and receive care integral to their rehabilitation, especially if they are postponing a very much needed surgery.
Proper prehab is very important. We are sending out updated home exercise programs to patients who are in need or inquire about options. Many of these people would like to stick with a few stretches to do on their own through the day to get them through this hard time until these social distancing restrictions are lifted, and they can move forward with their scheduled surgeries.
Additional recommendations for home care before surgical intervention (things to know for self-care at home and modalities which can be self-administered):
The use of Kinesio Tape is helpful with injuries. If applied correctly the tape will lift the skin, slightly increasing blood flow to the area of injury. Blood flow brings healing nutrients and oxygen to the injured tissue.
Strengthening and exercise. While stretching is important for reducing injuries, strengthening is a crucial component to preventing an injury from occurring and during the prehab processes. With proper strength training (under the guidance of a licensed PT–virtual PT can work for this), the body will not be so susceptible to overload from repetitive motions which can cause inflammation. Exercising regularly can stimulate the body to produce natural pain relievers called endorphins.
Over the counter anti-inflammatory or NSAIDs can reduce swelling or inflammation to relieve minor aches and pains.
Use a home TENS unit. This can be helpful and reduce elbow pain by delivering small electrical impulses through electrodes. TENS is a noninvasive method for relieving pain
Eating healthy, staying hydrated, and complying with your home exercise program until you can get your surgery is important and has many positive effects on the body improving overall energy levels and mood.
Get fresh air and exercise. These have so many positive effects on the body mentally and physically. I also would recommend trying not to nap too much throughout the day.
Focus on your prehab routine. Prehab is always recommended before surgery and leads to a better prognosis and quicker recovery time. This is a great opportunity to continue proper prehab and strengthening before going under the knife.
Proper ergonomics matter. As more and more people are working from home it’s important to remember to stay in a proper ergonomic position to avoid musculoskeletal problems. You do not want to get into a situation where you are having additional issues besides your injury that you will be needing surgery for. If working from home you want to invest in the proper office chair with adjustable features such as back rest, arm rests and lumbar support otherwise you likely to develop neck, upper back and low back discomfort.
Improper economic setup can wreak havoc on the body. Sitting on a couch using a laptop causes the body to slouch forward. Over time, forward head posture can lead to muscle imbalances as the body tries to adapt and find ways to hold the head up. Some muscles become elongated and weakened, whereas other muscles become shorter and tighter. Overtime, this will cause a decrease in the cervical spine curvature resulting in neck pain which can include degeneration, bulging or herniated discs, pinched nerves and poor posture.
Stretch to improve posture. Proper stretching will improve posture, align the shoulders and restore the curvature in the spine while preventing musculoskeletal imbalances as well as aches and pains.
Adjust accordingly. I always tell my patients that they should adjust their position every 20 minutes. A trigger point or knot (a taut band in the muscle that becomes tender to touch) can take 20 minutes to form if the body stays in a static position. So get up and move and you are less likely to have aches and pains. The more regularly you stretch, the better it is for your body. The home exercises we usually prescribe to our patients include 4-5 stretches that we recommend performing 2-3x a day for optimal health and wellness and to improve function.
We’ve had to make this choice, which is not fair, where you are a patient in pain and we want to take care of you, but we have to decide if its safe to go ahead with that interventions.
When you weigh the risks and benefits—someone getting the infection or putting others at risk—it’s real. You are healthy staying at home and most of our patients are elderly and in the high-risk group. I try to help the patient to understand that I know they are in pain and I can give them something for it as opposed to risking this procedure when you may come in contact with the virus.
I understand it painful, but the patients I talk to now at home are getting better. They’re resting. They feel better because they’re not working or doing as much. They’re not driving for an hour or two through L.A. It’s a forced rest. Suddenly, they’re not doing the work they do every day and a reasonable percentage of patients are feeling better and have less pain.
Neel Anand, MD Professor of Orthopaedic Surgery and Director of Spine Trauma Cedars-Sinai Spine Center, Los Angeles
Do the best you can to continue your nonsurgical treatment to help manage the pain through this time when we are not allowed to do elective spine surgeries. That can be from their nontreating doctors, medication, physical therapy, injections, chiropractic, massage, etc. We have encouraged our patients to keep in touch with us for virtual visits because patients’ conditions can change and become urgent or nonelective, and we can do surgery in the right circumstances.
For our patients scheduled for surgery and just in a holding pattern. They’ve received exercises from a physical therapist or some online educational resource we can point them to while they wait for the surgery. For new patients, we can recommend they see a physical therapist. Most are doing an initial assessment and then using virtual technology to continue treatment plans for the patients.
We try to reassure patients that we are in the same scenario together; there’s not a lot we can do. We remind them that as soon as we get the green light, we will resume scheduling surgeries.
For pain management with prescriptions, in certain states the governors have relaxed the restrictions for online prescription writing and the federal government has relaxed some of the restrictions for cross-state prescribing.
Our patients have been extremely flexible and understanding but want to clarify: the reason elective surgeries were canceled was to help minimize the use of resources like doctors and nurses, ventilators and beds in hospitals. As the COVID numbers continue to increase, we want to keep patients out of the hospital since hospitals.
There are some clear guidelines as to what conditions are considered nonelective, like broken bones in the spine that were causing intractable pain and disability. We’ve had patients with trauma to the spine where they have an unstable injury to their spine with high risk spinal cord injury. They can have surgery in this COVID era because these are nonelective surgeries.
Dr. Richard V. Chua, MD, FAANS,FACS Clinical Professor, Department of Neurosurgery University of Arizona College of Medicine