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from Gainesville, Florida. Yeah. Five live presents conversation from the University of Florida. A discussion of social, political, scientific and religious issues of the day. Your host is Dr Michael Began in professor of history and Ethics, an assistant dean of the College of Liberal Arts and Sciences at the University of Florida.

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Mhm. Mm. Yeah. Hello and welcome to another conversation. And this time my guest is William Friedman, Dr. Assistant professor of neurosurgery and neuro science in the College of Medicine of the University of Florida. Bill, welcome to conversation. Thank you. My pleasure to be here. It is good to have you here for a number of reasons.

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Uh, first of all, we're going to hear about a new surgical procedure that will be of interest generally. But more specifically, we're going to hear about that procedure as it was practiced upon notable Floridian at this particular moment in our history. Namely Wayne Piece, the starting quarterback of the University of Florida fighting gators.

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Now, Wayne is an individual who sustained an accident which caused an injury to Well, what was the injury? I'll let you describe it. Well, he had what we call a herniated or ruptured disc between the 4th and 5th lumbar vertebrae. And he actually sustained the injury during a pickup basketball game a little bit surprising in view of his more strenuous activities on the football field.

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But that's not an altogether uncommon history in athletic injuries. Is this because of perhaps a sudden move or unexpected jolt? Exactly. That's perhaps his spine had been somewhat weakened in the past, maybe even dating back to high school, because of his football activities, and the moment was right for the herniation to occur.

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Now, when you talk about the lumbar zor, the vertebrae is what are these? These are the bones that make up the spine. They're actually 33 separate vertebral bones that make up the spine, which travels all the way from the neck down to the coccyx. And the five lumbar vertebrae are the ones that were particularly concerned with when it comes to lumbar disc disease.

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Where are they? Are they the upper part of the spinal column in the low back? The low back? That's correct, All right. That's where a lot of people seem to experience injury or pain, absolutely low back pain and herniated disk, which is when cause of low back pain is a very, very prevalent problem in the United States, especially affecting working men working age men.

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I'm going to listen with great interest because I have low back pain. But then I'm told just about every American male my age has some modest low back pain. At some point in in in the life of every American male, there is an excellent chance of sustaining an episode of severe, low back pain.

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Now tell me what a disk is because his injury was properly speaking. Ruptured or herniated disk? That's right. The disk is the cartilaginous uh, mu Ko Polly Sacha, Right is the chemical term that we use material that that cushions the bones that make up the spine.

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It's called an inter vertebral disc because it lies between the vertebral bodies. It has a tough outer lining called an annual US and a softer inner portion called the nucleus. And if that annual asses torn or traumatized, then the nucleus can squirt out through the annual this and press on the nerve roots going to the leg.

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And this is what is responsible for the typical syndrome involving leg pain and neurological findings, including weakness, numbness and reflex changes. When you say that the nucleus can squirt out under those circumstances, it almost seems as though you're describing a liquid. It's gelatinous would be a more accurate description.

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Mm. It's not like the cartilage. Our ears are cartilage, are they not correct? And the nose as well? Correct. It's a different kind of cartilage. It is a cartilage, but it has a different kind of composition. The inner part. The nucleus has a very high water content, and that is what makes it different than the ear or nose cartilage and makes it softer, especially in young people.

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And its function in the spine is, too. Be a kind of what. It's a shock absorber, basically, and it also contributes to the bending, and a road auditory ability of the spine enables us to turn the way we do can. Personally, it's responsible for that. Now is the low back area, that district in which most people experience herniated discs.

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Absolutely. The two lower low back disc we call them the L 45 and the L five s one discs are by far the most common areas of herniation And that's because that area of the spine is the part which is subjected to the greatest stress. Now, when Wayne experienced this injury and his case is widely publicized and he has allowed it to become so, and I'm glad because it gives an opportunity for people to learn about a new surgical procedure that can help many.

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When he had this particular accident, what was the first prescription? What was the, uh, the diagnosis? And, uh, the mandate of the physicians in charge? The first mandate, uh, and and taking care of a lumbar Disks syndrome is bed rest. The vast majority of herniated disc problems will improve or resolve completely with bed rest, so we usually try a week or two of bed rest with pain medication and sometimes muscle relaxant medications.

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As a first step. Well, that doesn't cause the nucleus to return to its original position. Well, gelatinous substance. In fact, that's exactly what can happen when you're standing or sitting uh, is even worse. These positions will put more stress, much more stress on the disk than if you're lying down.

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So if you lay down, the pressure within the disk is considerably reduced and if the disk is not completely squirted out into the spinal canal, it can retract back into the disk space where it belongs and the covering reseal it. The covering doesn't reform, but new scar tissue can form, which will hold the disk in place.

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And the pain is caused by that gelatinous substance impacting against the nerve cords. That's right. Nerve roots, nerve roots. Correct. All right now what happened in Wayne's case? In Wayne's case, a short course of bed rest did not produce any significant relief. And when we reach this stage where conservative therapy does not appear to be helpful, then we go to the point where further diagnostic tests need to be performed to confirm the clinical impression of disc herniation.

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And those tests include a C T scan, a cat scan, which is a relatively new X ray technique of the disk. And this is a noninvasive, painless test, which can visualize the disk well and tell us whether there is a herniation presence and the stand by the old standby.

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My biography is also quite commonly used to identify a disc herniation. Now is that a case in which you introduce a die. That's right. A mile a gram involves doing a spinal puncture with a very small needle. We use local anesthesia novocaine and introduce the needle and then inject a dye into the spinal canal and take a series of X ray pictures to see whether any of those nerve roots are being compressed by a disk.

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And it showed up positively in this instance. In this instance, uh, and I should add in. In most cases where the clinical impression is disk, the biography and CT scan will confirm the presence of a disc herniation. And that was the case in Wayne pieces problem and then determination was made to enter by a new surgical procedure and make a repair.

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That's correct. After the diagnosis is confirmed by the X ray studies we just mentioned, then we have a a collection of operations from which we can choose depending on the patient. The area of disc herniation, the type of disc herniation the conventional operation was and still is where it is practised more traumatic than the procedure that in the end you followed what is the conventional surgical procedure here?

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The conventional operation, I should say right off the bat is the tried and proven method for treating lumbar disc disease, and it is the standard against which any new operations have to be measured. It involves making a small incision directly in the middle of the back, stripping the muscle off the spine and then removing a small amount of bone from the posterior part of the vertebral complex that is called a layman ectomy.

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We then visualize the affected nerve roots, move it to one side, find the disk and remove the disc under direct vision. Replace the disk or just remove it. The disk is rarely replaced with any substance. In a fusion is rarely required. You can lose two or three of your disk and really not miss them at all.

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We don't actually remove the entire disc. That would be unsafe. We remove perhaps 75% of the disk, and they're generally is enough left to provide an adequate cushioning function with that conventional and, as you say, tried intrude uh, tried and true operation. There is some trauma to the muscular structure and well, that's correct, and it results in a longer recovery period than what you have done in the peace case about How long would it take somebody to recover from that?

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The average period of time for getting back to a sedentary job after a lumbar disc operation through the back is about six weeks for getting back to playing collegiate level football. We're talking about sitting out six months, perhaps, or something of that nature and allowing all the structures to to heal completely.

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But you were able to get Wayne piece back onto the playing field in time for the first game of the season. And how many weeks? Six weeks? Six weeks? That's correct. All right. Now let's talk about that procedure and let's turn to a tape that you have developed.

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And it begins with our mutual friend Dr Peter and Della Kado, who is the team physician for the Fighting Gators. Let's let's open with Pete talking about what is going to Peter was well, the conventional way to treat Wayne's particular problem in the past has been a trial of strict bed rest anywhere from 10 days to three weeks.

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And then, if the problem did not resolve significantly, two order certain diagnostic studies to determine number one that the problem is a herniated disc and number two. At what level exactly is the disc rupture that peace did not respond to conservative therapy To give them the best chance at a speedy recovery, Neurosurgeon William Friedman recommended Piece undergo an innovative surgical procedure called per cutaneous disc ectomy.

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This diagram illustrates the approach that we take in Peru. Catania's to step to me for purposes of orientation. This is the patient's right side. This is the back, and this is the stomach. A traditional back operation involves making a midline back incision, stripping the Paris Penis muscles away from the backbone, removing part of the bone here, retracting the nerve root and then removing the disk per Catania's to step to me, as you can see, takes a completely different pathway through the patient's side.

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First, a long speculum is inserted under X ray control down to the side of the disk space. Then a chest tube is placed down the center of the speculum. The speculum is then removed, leaving the tube traveling from the skin surface down to the lateral aspect of the disk space.

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We then use, especially lengthened knife, two in size. The side of the display case. Yeah, A variety of biting instruments are then inserted down the chest tube again under X ray control to remove the nucleus of the disk piecemeal. Yeah, a special angled instrument finally is inserted down the tube and used to remove the herniated area of the disk itself and the angle.

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I expected to wake it up to being sore, and you think of back surgery just really feeling bad. And I woke up and I I really didn't feel that bad, and I slept pretty much all day. And then that night the nurse came in. And if you want to walk around and I said, Should I be walking around?

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So if you want to your vine So I got up and walked. Raft Piece was released from the hospital the next day because of the shortened hospital stay. The per Titanius disc removal costs about half what conventional back surgery costs. The removal of the disc does require time for the spinal column to readjust.

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I would say that anybody who has a disc syndrome is prone to develop further back problems, and for that reason we routinely prescribe a set of back strengthening exercises. Ah, to prevent that kind of long term complication. For the Florida passing whiz, the exercises have proved beneficial, making them more flexible than ever.

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And the surgery promises to be a virtually painless option for many patients who require the removal of bulging or herniated discs in the lower back. It helped me. It gave me a chance. Whether it was, I wouldn't have a chance and and you know it's not guaranteed yet.

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But, uh, at this point shoot, I'm I'm excited and I feel great and looking forward to football again. I want to thank Warren Croak and Lynn Jones and others who are responsible for that fine tape. And isn't Wayne piece of great fellow? He's a super guy, no question about it.

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That's a fascinating film. It showed the operating room scene not of the procedure that was practiced on Wayne piece, but of another and typical procedure of the same kind. How long does such an operation last? The actual surgical time is approximately 15 minutes, 15 minutes only.

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That's right, as compared with a conventional time of what I'd say that the average conventional operation is about an hour now. There are some slides that you have here, and I think it would help us if we could see them, because they slow down the operation somewhat so that we can understand it better.

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Let's show the first of those slides, and if I understand correctly from the tape, we just saw the patient is lying on his or her side. Is that correct? That's right, is the back to our left as we see the screen, the back is to the left, and the stomach is to the right.

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And coming in from the from the upside is a specially designed speculum, which is inserted under X ray control to the side of the disk space. Now what is a speculum? Speculum is just a long metal tube. Basically that that is, that is placed first. Then we open that tube up a little bit and run a plastic tube called it just a chest tube.

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It's called down the middle of the speculum. Now what are we seeing there that's colored red? And then what is colored white? The white structure is the vertebral body, and the disk is in the middle. The nucleus of the disc is actually herniated out and at the very bottom of the screen, you may be able to visualize the disc pressing against a nerve root.

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The red structures are the muscles that are found at the side and the back of the disk space, and that massive muscles has not had to be penetrated. With this procedure, you come through just a narrow band of muscle. Well, the difference between this operation and the traditional operation is that we make a very small pathway through one muscle to do a pro cutaneous dis removal, whereas in traditional back surgery, the muscle has to be completely stripped away from the spine.

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All right, let's take a look at the next slide, and we see contact made now with the vertebrae. That's right. In this slide, we have removed the speculum, and now we have a clear plastic tube going from the skin surface, down to the side of the disk space and down the middle of that tube.

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We have inserted a special knife, and we're now in season the outer lining of the disc, the annual US of the disc. Are you following this on television? All the while, we have a what we call an X ray fluoroscope in the O. R. Position so that we can constantly monitor the position of these devices on an X ray screen.

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And you can cut that accurately. And finally with the x ray picture that you see absolutely. That's amazing. Now here is the third of our slides. What are we seeing now? Well, in this slide, we have opened a hole into the side of the disc and we're now reaching down the plastic chest tube with a biting device called a Ron juror and removing the nucleus of the disc, the herniated portion in small bites.

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Oh, it does not come out all at once. No, it doesn't. Mhm, is it? Uh, you say it's gelatinous. Does it tend to fall apart or come in clumps or its fragments? It does tend to fragment, and that's why we take it out in more or less a piecemeal fashion.

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And you can be sure with the vision that you have through the fluoroscope that you have gotten every part of that well again, with this technique, as with all back operations, we cannot remove the disc entirely. That would be unsafe. Our objective is to remove the great, the greater portion of the central part of the disk.

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And we rely on our preoperative test to assure us that by doing that kind of procedure, any remaining disk will then collapse back into that central cavity that we've created. Now this is the last of our slides, and this is not. This is the last slide.

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It may be a little bit off the screen to the bottom, but we're reaching down with an angled biting device to get that herniated portion of the disk that was pressing on the nerve root itself in that picture. Bill, where are the nerve roots? The nerve roots are directly behind the disk, so we do not see them from this angle there, directly to the left of the white structure.

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They can be visualized there, I say, Well, that's fascinating. That is a remarkable series of pictures, and they help us to visualize what this operation is about. This is an operation that was devised by a surgeon at the University of Miami Hospital. I understand that's right.

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Dr. Robert Jacobsen devised the operation at least as it as it is in its present form and other surgeons around the country are using it. There is one other surgeon that I'm aware of doing the operation. He's in New Orleans. So you and he and Dr Jacobson are the only three in the country now correct using this procedure.

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And are there others like it? Are, is this technique so successful that it has caused you and others to think of how it might be used in other connections as well? For neurosurgery, there are several other possible applications. One is the diagnosis of infections of the disk space, which can be difficult with other techniques.

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This gives us the ability to biopsy a disk and look for infection very easily. The other is the biopsy of bony tumors were spinal tumors that affect the spinal canal. I'm wondering if, like arthroscopy and orthopedic surgery, you could put a little light and camera down that same shoot.

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Well, we've actually done that. We've looked down the chest tube with a a modified telescope of that kind, and I'd have to say that what we saw was not tremendously enlightening in terms of helping us do the operation. That is a possibility for future development. Now, what advice would you give in General?

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Of course, you can't be specific to people who are watching our program listening to your comments about this new operation. Seeing the pictures, what would you say to them about their possible need to have this kind of operation or or some other? But we're very optimistic about this operation.

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Our initial results have been very good. I should emphasize that we're in the early phases of looking at this operation. We do a very extensive and very careful screening of the patients who are potential candidates for Per Catania's disc ectomy, and a number of them are found for various reasons to to be unsuitable for this operation.

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If that happens, then we have the alternatives of traditional back surgery or the other new technique called chemo pai pain injection, chemo nuclear isis, where an enzyme is injected into the disk and it actually dissolves the nucleus that we've been trying to remove piecemeal with this procedure.

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What would be some reasons why a patient would not be an apt subject for this operation If the patient has a herniated disk at the disk space at the lowest disk space L five s one. We cannot safely reach that space with this technique. So approximately half the patients with this creations are not candidates for this technique just on the basis of their level of herniation.

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In addition, some patients with a disc herniation at the appropriate space have undergone. A herniation were in the disk, actually is squirted out into the canal, and it's completely disconnected from the disk space. In that case, we cannot get to it through the sod. And the other problem that we occasionally encounter is that our preoperative screening screening test reveals that the patient has a loop of large bowel or a blood vessel that may be too close to the surgical path to make the operation safe, and you can determine how apt subject is for the operation by the CAT scan system of X rays.

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That's right. We've developed a very rigorous screening regimen where in the patient undergoes a CT scan of the spine and a CT scan of the abdomen as well, and by looking at these X rays carefully were able to predict very accurately whether they would benefit from this surgery and whether the surgery would be a safe alternative There's a new type of X ray machine that Shands Hospital and the medical center are receiving one of the few institutions in the United States to receive it.

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I believe it was originated in Germany, and it has the title resonance in it. Are you familiar with that? No device. That's right. That's the NMR scanner NMR, the initial stand for a nuclear magnetic resonance. And it's a very exciting new technique, which may be very applicable to lumbar disc disease as well as a wide variety of other medical problems.

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It has the advantages of not requiring any radiation to be administered to the patient, to give us a very clear image of various kinds of pathology, and you get almost a three dimensional picture of the body You do. You have the ability to reconstruct the image in multiple different plans, which is a distinct advantage over the more conventional radiological procedures we're using now.

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And let us just remind ourselves from the ninth grade, when we studied biology and physiology, just what the spinal column controls in our body down there at that lower back region. When we talk about nerve roots, what's going on there just briefly. That's controlling well, the nerve roots that are coming off at that level, uh, innovate all the muscles in the legs so they're responsible for all the motion of the legs, all the sensation in the legs.

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And in addition, the innovation to the bowel and bladder are controlled at that level. So a lot of involuntary as well as voluntary muscular movement. That's cruise control. But that's right. Uh huh. And is it possible with a herniated disk that those nerve roots could be irreparable, irreparably damaged, thus resulting in paralysis of any of those?

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Yes, this can't happen. A severe herniation can cause complete paralysis of the legs and paralysis of ballon bladder function. That's unusual. The more common situation is severe pain syndrome, accompanied by weakness of selective muscles and minimal loss of sensation or reflex, is one of the things that strikes me and following as an amateur.

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The advances in medical science is how remarkably the surgical profession has been able to enter the body with minimum damage with minimum trauma, minimum pain, and you're even getting people up out of their beds very quickly after operations on their feet again and moving Well, that's that's very true.

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And I think the trend in surgery is towards smaller and smaller incisions. Less and less trauma to the body structures. Wayne piece, for example, left the hospital the morning after his operation. And that kind of quick recovery and early discharge would would be impossible. With most other operations.

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You mentioned arthroscopy before, which is a technique used to remove, uh, cartilage problems in the knee. And and the same principle applies. They're very, very small incisions, uh, surgery through a small tube with consequent quick recovery and early discharge. Bill, thank you very much for being with me on conversation.

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It's been a pleasure. My guest has been Dr William Friedman, assistant professor of neurosurgery and neuroscience in the College of Medicine of the University of Florida. And thank you for being with us for a conversation. Mm mm. Mm hmm. Uh huh. Mm.