Inside the OR
A front-and-center look as a Rothman spinal surgeon makes a life-changing repair.
Dr. Mark Kurd preps for surgery
Patients with lower-back pain are faced with four options: live with the pain, take opioids to relieve it, try alternative therapies, or undergo surgery. Many choose drugs, which address the pain but not the problem—and they can lead to addiction. Meanwhile, spinal surgeons are making surgery more and more appealing, perfecting techniques to permanently fix herniated discs. Here’s one patient’s story.
That Ruth Henninger is excited about her surgery speaks volumes about her pain and how long she’s had to endure it. “I want to be able to pick up my daughters and play with them and hug them,” says Henninger a week before her June 13 microdiscectomy at Bryn Mawr Hospital. “I want my life back.”
Henninger’s path to the OR began on Jan. 27, 2014, with tightness in her right leg. The 37-year-old mother of two works in daycare and spends most of her life running after kids, including her own, so she didn’t think much of it. But as the day wore on, the discomfort segued into unrelenting pain. “It was worse than giving birth,” she says.
Henninger ended up in the Lankenau Medical Center ER, where it took two opioid injections to control her pain. A week later, Dr. Ari Greis, an orthopedic specialist at the Rothman Institute, determined that Henninger had a herniated lumbar disc and prescribed physical therapy and anti-inflammatory medication. Within six months, the pain was gone. By January 2016, however, it had returned tenfold. The pain was so severe because the herniation was outside the spinal canal. “It hurts like hell,” says Rothman spinal surgeon Dr. Mark Kurd, offering a frank description of the far-lateral disc herniation he saw in a second MRI.
Henninger had exhausted her nonsurgical options. The pain was so severe because the herniation was outside the spinal canal, instead of inside. “The herniated part is pushing on the dorsal root ganglion, the brains of the nerve,” says Kurd.
A microdiscectomy removes the herniated part of the disc, decompressing the nerve. “I don’t want surgery, but I don’t want to be in pain forever,” Henninger says.
The morning of June 13, Henninger is lying on a gurney with tubes in her arms and tears in her eyes. She clutches two tiny dolls—good-luck gifts from her daughters. “I’ll be OK,” she says. “Dr. Kurd is going to fix me. I’ll go home and be with my girls.”
June 13, 2016, 10:05 a.m.
It’s the third surgery of the day for Dr. Mark Kurd and physician assistant Carmen Carrero. They do eight to 12 of them a week. Of the 60 percent that are lumbar-related, a third are microdiscectomies, and less than five percent of those procedures include far-lateral disc herniations. It will take Kurd time and precision to reach the herniation. “The way we’re coming at the disc is outside in, instead of from inside the spinal canal,” he says.
For a surgeon, this is considered a small procedure, meaning that it’s localized to one disc and only part of it will be removed. More complicated surgeries involve replacing the entire disc—or several discs—and stabilizing the spine with titanium plates.
Henninger’s microdiscectomy is small in another way: Kurd’s operating section is four millimeters square, making surgical loupes necessary to magnify the area. A surgical headlight will help him see through blood, muscle and bone. “The smaller the incision needs to be, the more accurate I need to be,” Kurd says.
Kurd makes his first critical decision: where to cut. Discs are referred to by region—cervical, thoracic, lumbar or sacral—and the levels at which they sit. The cervical spine has seven levels, while thoracic has 12, lumbar five, and sacral five. Henninger’s herniation is between the third and fourth levels in her lumbar, L3-L4.
Intraoperative fluoroscopic images are taken with a giant, mobile machine so Kurd can see the lumbar spine in real time. “I’ll make a skin incision, and then we’ll do another X-ray to check that the incision is where I want it to be,” says Kurd. “We’re localizing to the appropriate level, then we move from there.”
Kurd works slowly, spending 30 minutes traversing the few centimeters to the herniated disc. He doesn’t speak, but the OR is still surprisingly noisy. Nurses chat, technicians move equipment, and the Eagles’ “Hotel California” plays over the sound system.
Kurd remains silent, bending over the table to look directly into the hole in Henninger’s back. The physician assistant’s eyes follow Kurd’s hands, anticipating his needs for suction, gauze and other instruments. Behind the surgical loupes, Kurd’s gaze is intense—eyes shifting only slightly, hands even less. He’s aiming for the microscopic stub of bone on which the herniated disc bulges. Inflammatory tissue surrounds the herniated part of the disc, and Kurd has to remove it without damaging the rest of L3-L4 or its adjacent nerve.
Seeing inside a patient’s body feels like a breach of privacy. The view is both gory and awe-inspiring. A human’s interior architecture is as beautifully complex as it is extremely delicate. A single disc, barely displaced in the spine, can cause tremendous pain. “It’s difficult to explain how someone can come to hate their body,” Henninger says a week before her surgery. “This body is causing me pain, and I’m mad at it. I’m angry that this happened to me, and I’m afraid that I’ll be in pain forever if Dr. Kurd can’t fix it.”
In watching a surgeon’s instrument touch a patient’s exposed spine, one can begin to grasp the massive responsibility of cutting into a living body, even to fix it. For a spinal surgeon, success or failure is measured in millimeters. Precision is critical—one wrong move, and the nerve to Henninger’s leg could be damaged or severed.
“I got it,” Kurd says.
At the tip of his instrument is a fragment of white tissue that’s about the size of a sesame seed. It’s only a piece of the disc; Kurd still needs to remove the remaining microscopic particles. Then, to make sure he got them all, he’ll test the nerve next to L3-L4. If it’s fully decompressed, it will respond when he activates it.
The nerve does exactly what Kurd wants it to do. Henninger will feel better as soon as she awakens, but it will take several months for the nerve to completely repair itself.
Kurd checks the newly decompressed nerve a third time. “I’m appropriately neurotic,” he says, prompting a laugh from Carrero, who hasn’t said a word for more than an hour.
Satisfied, Kurd prepares for the final part of the surgery. He irrigates the opening with saline, pouring a carafe of water into the hole in Henninger’s back. Blood-tinged water bubbles up like an anatomical volcano. Next, Kurd puts an antibiotic powder directly into the hole. It will be absorbed by Henninger’s soft tissue, reducing the risk of infection. Then comes the multilayer closure as Kurd sews together fascial, subcutaneous and subcuticular tissue. Henninger’s scar will be no more than three centimeters.
An hour and three minutes after it began, the surgery is over. Kurd and Carrero fist-bump with their bloody gloves.
Kurd heads to the waiting room to speak with Henninger’s husband, Mark. She should be awake in 90 minutes and will be able to go home later that afternoon. She’ll have a prescription for a muscle relaxer and a 30-day supply of hydrocodone. Kurd gives clear instructions for Henninger to be up and moving. “I don’t want her to be sitting a lot,” he says. “The less active she is, the more pain she’ll have from muscle spasms. If she uses the muscle, it will spasm less.”
Kurd sets expectations rather low. “She’ll have good days and bad days over the next few weeks,” he says. “It’s not a perfect trajectory. It can be a bumpy road.”
Follow-Up: Sept. 30, 2016
The day after her surgery, Henninger walked down the street by herself. On the second day, she cut back her intake of hydrocodone and switched to Advil. She stopped using it completely after a week. “Two weeks after the surgery, I was back at work and could sit, drive and move around normally,” she says. “The change was more noticeable than I hoped it would be—and it was almost immediate.”
The pain hasn’t totally vanished yet—and that's expected. Henninger acknowledges the psychological toll of the past few years. “There are still times when I move hesitantly, but then I realize that I’m no longer in pain and don’t have to be afraid,” she says.