Traumatologist – orthopaedist, spinal surgeon
Lecturer of the Traumatology Course for physician assistants
Does your back hurt? Don’t worry, you’ll have an operation in a minute!
Back pain is no longer only elderly people’s problem- also young, sporty and strong people, suffer from it due to different reasons. There are cases when a surgery is inevitable in order to get rid of the pain. However, there are situations when it is possible to decrease the pain and cope with the illness, applying conservative treatment techniques. Dr Agris Mertens, the traumatologist of Liepāja Regional Hospital talks about them.
- Let’s start our talk about the most common complaints of the back pain localization and their types.
- The most common complaints are about the pain in the lower back, the so called sacrum, and the pain in the neck part. Reasons and causes of the pain can be various. One of them is hard physical work, when the back muscles are overstrained or strained in an incorrect way due to which a human being feels pain in the lower part of the back. There can be very serious spinal damages as a result of hard work: vertebral offset, intervertebral disc hernia etc. Another reason could be work in bad weather conditions, e.g. in a draught , where the wind blows on the musculature, the nerve roots get inflamed and the human being feels pain. If we talk about the pain in the neck, then the people, who work for a long time in one and quite often uncomfortable position, e.g. by the computer, suffer from it most often. The reason for that is wrong ergonomic work environment when both arms and head are placed in an uncomfortable position. Musculature is strained in a wrong and dissymmetrical way, which in a log-term is manifested as pain in the neck. But in the summer season there are patients who have problems due to air conditioners in cars and offices. Wind blows on the nerves, they get inflamed and the pain of sore nerves is very excruciating.
- When a person has been in pain for a long time, most probably one of the first questions asked the doctor is whether there will be a surgery?
- People should not be frightened by all means. I would like to bring one comparison. When a mechanic sees a car entering the gate, they already sense what problem could be there. The same way we, spinal specialists, generally understand what the problem could be from the person’s gait, facial expressions, the way of sitting down and other features as soon as the person enters the room. When the person has been examined for the first time and their complaints have been heard, it is very important to set the diagnosis. Nowadays medicine is really advanced and there are so many ways to set the diagnosis that it is possible to check the spine in all its nuances and levels. And only after all necessary examinations have been performed, the patient is informed about the current diagnosis and recommended treatment options. But, of course, if the pain is severe, in addition to the diagnostics the doctor prescribes also the non-steroidal anti-inflammatory drugs to reduce the pain- it is a general practice.
- What do you think about the so called self-medication, when a person whose back hurts, prior to a doctor’s visit, first of all has tried out self-medication for a long time, taking various pain killers at home?
- If it has been done for a short time, I can’t say anything bad- the person is in pain. However, if it has been done for a long time, but the pain does not decrease, then there is a risk to lose time and get into even a bigger trouble, which can have irreversible effects in the future. During this period the disc hernia can press the nerve roots. As a result, the strength into arms or legs can disappear and even movement impairment appear. Sometimes it can be regained, but there are cases with irreversible effects. Sometimes time is extremely essential.
- Let’s look at the conservative treatment options in the cases when it’s clear that at least for the time being surgery is not necessary.
- I would like to say that you cannot judge the situation like that. Even if a doctor sees clearly the surgery would be needed, but the patient does not want it, I still try all options to treat in a conservative way. At first, there is the drug treatment and in most cases it is enough. If not, then I recommend the epidural block which is performed by a doctor-anaesthesiologist. It is a very effective treatment technique. The specialist inserts drugs into the spinal epidural space which removes oedema and inflammation. In the case of intervertebral disc hernia, when it seems there is no way without a surgery, complaints often change after the treatment and it is possible to do without surgery. However, if the complaints still persist, then it is time to think about surgery. Moreover, good results can be achieved with therapeutic exercise in case of a back pain.
- So it means the physiotherapist’s help is needed.
- Of course! It would not be a good idea to start doing exercise on your own, since the situation could even get worse. Not knowing how to choose the right exercise and load, the human being can harm the problem place. First of all, I would not recommend to start doing exercise during the acute painful period. Then the problem place needs peace. Medication should be taken which kills the pain and decreases inflammation. However, during this period the sacrum needs a corset, but if the pain is in the neck part, then the so called soft collar is needed, which relieves muscles. There is one more thing which I would not recommend doing during the acute pain period- going for a massage, as after the massage the pain may increase. During the acute pain period the problem place needs peace!
- Which is the right moment to make an appointment with a physiotherapist?
- When the pain has decreased and the patient feels comfortably. For the patient, who suffers from the pain in the back, it is very essential to train back muscles. But one should bear into mind, the physical activities which suit to a person in their 20s will not suit to a 60 year-old person. Just because of that it is important to consult a physiotherapist, who will find the most suitable exercise according to the person’s age and health problems.
- Physically active people also suffer from back pain and they are confused: why? Doctors say, “Do sport and there won’t be any problems.” But as we see, there are. Here I mean the popular sport, not professional.
- I strongly support sport! Most often the problems come up in sports where dissymmetry dominates, e.g. tennis, basketball, volleyball etc., where the load is more on one side of the body. Therefore it would be highly recommended for these people to go also swimming in addition to their favourite sport. Moreover, it would be necessary to do it even if there is no pain in the back, because back muscles have to be reinforced in a symmetrical way and swimming is the most appropriate for it.
- Autumn is time, when people after their holidays have come back to work, where most of the time they spend sitting. So to compensate that, they quickly take up sports activities.
- It is very good. However, after a break in sport or for the people who have just decided to take up physical activities, my sincere suggestion is not to exaggerate. Therefore it is important to find a sensible coach or sports instructor, who will introduce every person with the sport in compliance with their physical condition and bodyweight. And the person will not have to queue up in back pain for a doctor in a week, which could happen if one does sport in a wrong way. If a person is overweight and without any experience of physical activities, I would highly recommend to start physical activities with walking – in the beginning slowly and then gradually increasing the speed. Nordic walking is ideal without any sharp movements, but complete physical load, which also improves breathing. But, as I have already mentioned before, swimming is the best kind of sport, also cross- country skiing.
- Let’s talk also about the previously mentioned aids such as lumbar corsets and soft collars for the neck. Why are they efficient and recommended?
- As I have said before, they relax musculature. Moreover, the lumbar corsets are also recommended for the people who work hard physically in order to protect their backs from trauma and overload. Each spine disease needs a different corset and only a spinal surgeon can say which one. The corsets can be purchased in special shops where there is a specialist who will help to find and try on the necessary item for every individual. It is as important as the right size of shoes.
- We talked about therapeutic exercise, but let’s also remind of different physiotherapy procedures, which are also used successfully in back pain treatment.
- Physiotherapy procedures are very helpful in case of a back pain and nowadays their range is pretty vast: electric procedures, different water procedures and various applications, etc. The physical therapy specialist will determine which ones of them are the most appropriate after the examinations, patient’s complaints, consultant’s recommendations and the patient’s general health condition.
- Recently taping procedures have become popular, which initially were applied only to athletes, now also in cases of various muscle pain, also back pain.
- I would call it as a fashion trend. It is a popular and efficient physiotherapy technique to release pain in injured muscles and kill the pain in joints with special adhesive tapes. Of course, in serious pathological cases they will not help, but surely, taping is one of the back pain treatment possibilities. There is one more aid - ointments, which can also reduce pain in the beginning.
- Who do you think is the specialist one should go to in case of a long-lasting and excruciating back pain?
- First of all, it should be the GP. However, if it is really a lasting pain and the initial drug therapy does not help, then it is very important to turn to the spinal surgeon. And this is not because the specialist acknowledges an operation as the only means of treatment. This is an absolute nonsense! This is a specialist who works on a daily basis with people who suffer from back pain. Thus they can notice the nuances which other specialists might not notice. Even though it seems that everybody has the same kind of back pain, there are still so many nuances which cannot be explained neither in two nor three interviews. Each case is very individual, so it has to be assessed individually as well. It happens that sometimes the patient’s problem seems really tiny, but eventually a surgery is necessary. However, the patient who had severe problems and we thought there was no way without a surgery, we still could treat with conservative techniques. It is important to find a specialist who is experienced in the particular area.
Agris Mertens: how to treat intervertebral disc hernia
AGRIS MERTENS, the spinal surgeon, works for Liepāja Regional Hospital, developing spinal surgery and performing complex large scale operations. One of the most common ones are the release of the nerve root in case of the intervertebral disc rupture.
During the talk with the doctor, we try to find out its causes, treatment options and the quality of life after the trauma.
- First of all, could you, please, explain what exactly the intervertebral disc hernia is?
- Human spine consists of vertebrae and between them there are natural shock absorbers which are filled with amorphous, similar to gel, substance. In order to avoid spreading of the amorphous substance, it is surrounded with a fibrous ring. Disc hernia appears when the ring breaks and the amorphous substance gets out.
- Is it very painful?
- Yes, it is. The spinal cord and nerve roots are the most important parts of the spine. In the disc hernia case the amorphous substance, which has spread out from the intervertebral disc, presses the nerve root. Even the smallest irritation causes severe pain.
- Of course, the patient will immediately ask: why did it happen to me?
- Honestly, nobody knows it exactly yet, why the intervertebral disc hernia happens, but we do know its influential factors. They could be incorrect lifting techniques, different rotation movements, excessive physical load and other reasons. In addition, genetics also is very important.
- Could sports activities or insufficient warm-up before them also be one of the reasons for such a trauma?
- Even though excessive exercise is not good, the spine needs movements. Therefore a special set of exercises has been worked out for the patients who suffer from spinal problems in order to strengthen the back muscles. I would recommend warming-up before sports classes, since fast increase of workout without any previous warm-up can lead to trauma – I, as a traumatologist, know it for sure. One should remember that every age group and physical condition has a different load. Thus sports activities have to be started under a professional coach’s supervision.
- Intervertebral disc hernia is not just elderly people’s problem, is it?
- According to statistics, most patients of this diagnosis are aged from 25 to 40. They are physically active people. However, when a disc has raptured, they are not able to have as active lifestyle as they used to have. That is why a fast and efficient recovery is necessary for them in order to be able to return to work and the previous active lifestyle as fast as possible. But, to start an efficient treatment, first of all, it is necessary to set a precise diagnosis.
- What is the best way to do it?
- The first visit to the doctor is very essential. During it the doctor listens to the patient’s complaints, assesses the neurological condition and prescribes the necessary examinations. Modern medicine is developing and so are the radiological examination techniques. One of the most modern ones, which has been widely used in surgery, is Magnetic Resonance. It is a safe examination for the patient, in which the spinal canal with its surrounding structures can be visualized well. The examination shows precisely the disc hernia localization and shape. Before Magnetic Resonance was available, Computed Tomography examinations were the most precise diagnostics. However, these ones do not show completely all nuances. Combining the radiological findings with the patient’s complaints and neurological condition, the doctor can make a quick decision about the further treatment.
- Hopefully, operation is not the only option, is it?
- No, it isn’t. There are cases when the doctor can also treat in a conservative way: with medicine, physiotherapy procedures, therapeutic exercise, also applying the epidural block during which the doctor feeds in some drugs in the spinal epidural space. As a result the pain is reduced and quality of life improved.
- Does the conservative treatment only kill the pain or also release the pressed nerve roots, which is the real cause of the pain?
- The intervertebral disc ruptures differ from both the shape and localization. There are cases when the substance oozed out of the raptured disc is big and presses strongly the nerve root. However, there are also cases when there is a slight rapture in the disc and its bulge is tiny. Conservative treatment without an operation is performed in cases of small disc raptures due to which the nerve root calms down and does not cause any pain to the patient. In each case the treatment is individual, and the most appropriate treatment technique can be prescribed by the operating spinal surgeon.
- Is there a guarantee that after the treatment the pain will not return?
- There is no such guarantee! It is possible the pain may come back. However, taking into account the doctor’s prescribed treatment, doing exercise regularly and attending the swimming pool, the chance of it decreases.
- Which are the cases, when after all examinations, the spinal surgeon knows surgery is the only solution?
- Mostly they are the acute cases. For example, when a patient feels weakness in legs together with bowel and bladder dysfunction. This condition in medicine is called “cauda equine” or horse’s tail syndrome, where surgery is urgent. The patient may also have foot paresis or weakness, when the patient keeps tripping over. Such a condition also requires surgery.
- Could you, please, describe the procedure of surgery, as lots of people are scared of any surgical interventions?
- The surgery is pretty safe. It is performed under general anaesthesia and it lasts for about one hour. The cut is quite small – about two centimetres long. To perform such an operation the surgeon needs optical magnification glasses which increase the nerve root for about four times, thus increasing safety of the operation. In order to access the raptured disc, the pressed nerve root has to be pushed aside, pulling it gently with special instruments. Thus the access to the disc herniation bag is provided, and the cleaning of the intervertebral disc gap can be started. Up to 70% of the damaged disc can be cleaned using special instruments, leaving only the fibrous ring of the disc. When the nerve root has been released, the operation can be finished, closing the cut with cosmetic stitches. In a year the place of the surgery cannot be seen.
- After the operation the recovery period follows.
- Taking into account the small tissue damage during the operation, as well as the relatively short operation time, patients usually feel well during the postoperative period. On the second day patients get up and walk, and on the third day they can go home.
- But it does not mean that sparing postoperative period mode does not have to be observed any longer, does it?
- Of course, it has to be observed! The hard lumbar corset has to be worn during the postoperative period and no heavy objects can be lifted at least for two months. Moreover, it is not recommended to sit for a long time during the first two weeks of the postoperative period. Whereas, starting from the third month, the person can gradually return back to the previous lifestyle: work, do sports and other activities. There are not many restrictions, but, of course, overload cannot be allowed. After these operations swimming and therapeutic exercise are recommended. A special set of exercises helps to strengthen the back muscles, thus patients can return faster to their previous lifestyle and physical activities.
- If one raptured disc has been operated, is it possible that after some time the same problem happens with another one?
- Definitely, rapture of one disc does not mean the other ones will rapture, too. However, there are patients who have got several raptured discs.
- When Magnetic Resonance is being performed to diagnose rapture of one disc, isn’t it possible to notice the problems with other discs as well?
- Yes, it can be diagnosed. An intervertebral disc quite often raptures on several levels. It can happen that on one level the disc has raptured, and in the examination it can also be seen that the disc above or below is also a little cracked. In such cases we make a decision to operate on the disk which creates the most serious problems. From my experience I can say that if the most problematic disc, which puts pressure on the nerve root, has been operated on, the complaints disappear and there is no need to operate on the other ones.
- Reading this interview, somebody may ask: what preventive measures could I take not to have problems with intervertebral discs? Have you got any suggestions?
- As I have already mentioned before, therapeutic exercise is very essential for people with spinal problems. It is a special set of exercises recommended by rehabilitation specialists. Another valuable measure is swimming, which also has been mentioned several times. And, of course, it is important to watch own weight, since overweight gives an extra load on the spine. Also too much stress can cause back pain, so it is recommended to be out in fresh air as much as possible and sleep well – worry less about daily issues and be optimistic.
Spinal surgery also comes into oncology.
Liepāja Regional Hospital is one of the few places in Latvia where complicated surgeries to patients with oncological processes in the spine are performed. We have a meeting with Agris Mertens, the traumatologist- orthopaedist, late in the evening, when after surgeries he still continues consulting outpatients. The queue is long: there are people who have an appointment for a particular time, but there are also patients with no previous sign-up. But they do know: they will have to wait for a longer time, but the doctor will consult everybody up to the last patient.
- When talking about oncological diseases, first of all, we think about the prostate, breast, gastric cancer, etc. Whereas, oncological problems can also be localized in the spine.
- Backbone is one of the most common localization places for metastasis- up to 70% of all metastasis. For instance, the lung, breast, kidney and prostate cancer often cause metastasis in the spine. Lasting back pain can be a precursor to oncological processes.
- If there is metastasis in the spine, how can a spinal surgeon help?
- It is complex work, because first of all a very precise examination is required to diagnose the illness. When the diagnosis has been set, then the decisions can be made about the further treatment policy. The decision is quite often made by the council of doctors, where they look at the treatment procedure in a multi- disciplinary way. Chemotherapy and radiotherapy are applied in oncological problem treatment, which is without surgery.
Despite the wide range of treatment options offered in Liepāja Hospital, not all patients can be helped, as quite often the malignant process is in its late stages. That is why I would like to remind once again: in order to diagnose the tumour in its early stages, patients have to look for the specialist’s help as early as possible.
- What are the modern diagnostics techniques?
- In the 21 st century the radiological diagnostics techniques have developed and diagnostics has become more precise. One of the most precise diagnostic techniques is Nuclear Magnetic Resonance examination, which can diagnose tumours not only in the spinal vertebrae, but also in the spinal cord.
- You have had cases when you had to perform spinal tumour surgeries, haven’t you?
- Yes, of course, I have experience with such, the so called intradural tumour, cases. This kind of surgeries are technically complex and with a high risk level. To obtain experience in such surgeries, in the beginning I went to Dr Artis Gulbis in Riga to study. Now we also perform the operations in Liepāja Regional Hospital. One of the recent ones, which we did together with Dr Gulbis was to a young man, who had had a lasting back pain. The tumour was found in a profound examination. The operation was successful, followed-up by radiotherapy, and now the patient feels well.
- If the tumour has been diagnosed, does it always mean application of a scalpel?
- No, not always! In these cases the decision about surgery is similar to the saying: “seven times measure and then cut once.” First of all, it is important to work out the treatment plan. There are not two equal patients- every patient has to be treated individually, depending on the tumour spread, localization and type. Taking into account all these conditions, specialists make a decision about the surgery volume and fixation type. In case of tumour the spinal fixation is extremely significant, since tumour destructs the adjacent tissues (makes them soft) and the spine loses its endurance. To avoid spinal destruction and to reinforce it, fixation with titan screws and rods is required. This way we provide stability in the spine during the postoperative period.
- This kind of operation lasts for several hours.
- That’s right. The surgeries, where the spine is stabilized with implants, can last for several hours. It depends on the fixation volume and tumour localization. Recently we have performed surgeries, where the spine is fixed frontally, supporting the vertebral body on special titan jacks. This kind of surgery extends the operative time, but it is more effective and patients recover faster.
- What other difficulties do you encounter during the operation?
- When operating on spinal tumour, bleeding is a big problem. Tumours are often highly vascularized, and there can be a huge blood loss during the operation. To decrease it, we try to perform the vertebra immobilization or blood supplying artery blockage with special microspheres or spirals before the surgery. A special catheter is inserted through the groin artery with a small cut and the artery supplying the metastatic vertebra with blood is found. Before the very immobilization or blockage a special contrast agent is fed in through the catheter, which helps to assess the tumour blood supply network. After its examination the blood supplying vessels are precisely blocked. Dr Lelde Kulmane performs such complicated and minimally invasive procedures in our hospital.
- What are the future prospects after the surgeries?
- It depends on the postoperative histological findings. It’s not always possible to perform radical surgeries where the tumour is taken out completely. Of course, it has to be taken into consideration that the patient’s lifeway, whose spine is with metastasis, is limited. Our main goal, fixing the spine, is to provide the quality of life for the patient, so that the patient after the surgery could walk.
- This kind of surgeries are very expensive. Can patients afford them in the post crisis period?
- The surgeries can cost several thousands. However, right now they are paid by the government. Also the hospital costs for the patients with an oncological diagnosis has been reduced. It is important to be aware of it, as lots of people are afraid of coming to a doctor, thinking they will not be able to pay for it. Therefore sometimes the diseases have progressed too far and it is not possible to help any more.
- Proceeding with our conversation about spinal problems, could you, please, tell us a little about the moment when a person with back pain should search for the spinal surgeon’s help, for, as we know, the first helper in any health problems is the GP. - Yes, that’s right! The spinal surgeon’s help should be searched after the GP has prescribed pain killers, the patient has taken them, but without any improvements. Then the specialist’s help is necessary because specialist will be able to prescribe purposeful examinations to set the diagnosis precisely. In my practice there are plenty of cases when a person complains about the back pain, but we find the problem in the hips and vice versa. And I can emphasize once again that people shouldn’t be afraid of coming to the spinal surgeon, as surgery is only performed in the case when it is really necessary and other types of treatment have not been effective.
- Can you explain why so many young people have a back pain nowadays? - Tumours are hardly ever found in young people. Their back pain is usually connected with sedentary lifestyle and work. I would recommend more movements and swimming in the pool at least once a week, as this really helps the back. Of course, if the pain lasts for a long time, the specialist’s help is necessary.
- Nowadays jogging is in fashion, but there are specialists who warn: this type of sport traumatizes the back. Have you got any recommendations for them? - I do not know any researches which would confirm that jogging damages the spine. So my only suggestion is not to exaggerate. If no sports have been done before, I would not recommend to start with jogging, but rather with an active and energetic walking and change gradually to jogging. Everything has to be done in a balanced way and regularly. This is my suggestion!
Dr Mertens, as a young and talented spinal surgeon, has had to answer questions about medicine and his work specifics several times, but there has never been a chance to talk about his hobbies.
“I try to spend my free time in an active way: now I am planning to take up tennis,” he says. “In the winter I do mountain skiing. In spinal surgery the long hours you spend in the operating theatre require not only mental effort, but also physical, so I am trying to keep fit.”
Correct posture prevents deformation risk
The school year has already started, when we can see pupils going to school with huge backpacks on their shoulders. When an adult carries it, they are sometimes surprised: “Do the little ones have to carry it on their backs?”
However, the heavy bags are just one of the reasons, why different posture problems appear during a period of time, whose most severe consequences are the spine deformation. “Preventive health improvement measures have to be taken- the back has to be relieved,”- traumatologist- orthopaedist Dr Agris Mertens says.
Load on the back has to be spread evenly.
“Posture problems is a topical problem with a tendency to increase in the modern society,” A. Mertens starts the conversation. Most often the cause of posture problems are found in childhood. Children’s bones are soft, flexible, and vulnerable to external pressure.
He mentions several factors, contributing to the wrong posture and spinal problems:
“First of all, one of them is different dissymmetrical kinds of sport, when only one side of the body is exercised and trained. For instance, tennis, basketball – where the ball is served, punted and dribbled just with one hand. And this is a primary reason, which later can progress and cause a serious back pain, developing into deformation,” explains the traumatologist. “Another essential factor- children often sit in a wrong position: bended, tilted to one side, one leg is bended, put under the body. It would also be important if parents thought about ergonomics of the child’s study place- have a desk and chair appropriate for the child’s height, so that the child could sit comfortably without bending the back or neck. Good lighting is important for the study place as well,” says A. Mertens. Of course, doctors all over the world emphasize the “age of computers” when talking about the wrong sitting position- the little humans sit bended in one position for a long time, replacing moving activities with the technology marvel.
“Of course, also the heavy bags are one of the most important posture formation and back pain reasons. Possibly, the child will not feel any pain at first,” says the traumatologist, who also teaches that the bag has to be carried on both shoulders. “Surely, parents’ responsibility is to check what is in the bag, whether children do not carry extra weight on the backs.”
Prevent the pain progression and deformation risk
In the beginning the first possible signals about the possible risk of the back deformation will be unnoticeable. “People will notice it in a period of time- if the spine is tilted to one or the other side, the pain will increase year by year and also the dynamics of deformation. The pain will increase, and only then the patient will go to the doctor with complaints!” says the specialist, pointing out that it is not a good idea to wait till the pain appears. “It’s important to do therapeutic exercise and swimming – they are the main preventive measures of spine and posture prevention. They are also recommend when there is no back pain or any form of scoliosis, which has to be treated surgically,” suggests A.Mertens. “Swimming is very important, as it develops different muscle groups and it is very good for the breathing system. Cross- county skiing is also one of the preventive sports activities to train the back,” he adds.
The traumatologist also emphasizes that spinal and posture problems will leave an impact on other organs as well. “If the spine is seriously deformed, development of the child’s inner organs will be encumbered,” the doctor warns. Deformation for adults is characteristic with posture problems and pain. It’s sometimes difficult to eliminate such deformations with preventive measures, as the spine is not so flexible. Nevertheless, therapeutic exercise is very important, as it helps to strengthen the spinal muscles.
Operations are expensive and complicated.
The pain due to the spinal deformation, which is irreparable, can be eliminated with a surgery, having a special treatment by a physiotherapist before and after the surgery. “The operation costs six to seven thousand euros. Implants, specific materials are necessary for that, it is a complex process. For young people under age the operations are for free- hardly any parent could afford such an operation for their child. Government compensates these operations very little– also hospitals work with losses, when performing such operations,” A.Mertens reveals the problem in medicine.
In daily life lots of people suffer from pain, and back pain is one of the most common one. It especially refers to people who work in the countryside in the autumn. Stress causes back pain and psychological discomfort, too, confirms the spinal surgeon Agris Mertens. Lots of patients with back pain turn to him as he is the operating spinal surgeon of Liepāja Regional Hospital, and about 10 % of them have chronic diseases which need surgical treatment. Nevertheless, specialist’s advice is provided also in other cases. If the pain persists in two weeks, the advice is definitely needed.
Sedentary lifestyle is harmful
“When working for days on a tractor during the harvest time, the human body gets tired very quickly,” A.Mertens describes the seasonality of back pain, “The new technology is friendlier. However, the problem is not in the technology, but with the incorrect body position- long-lasting, sedentary work without any breaks, extended working hours do harm both to the tractor drivers and office workers. Moreover, the cause of back pain is not always a mechanical one, quite often it is provoked by stress as well.”
People often think that back pain is due to osteochondrosis. However, the causes of pain are very different and individual to each age group. The intervertebral disc cartilage becomes less flexible with years. Uneven load, sedentary lifestyle, overload, spinal traumas quite often accelerate this process. When the intervertebral disc becomes thinner, the gap between vertebrae decreases, after which the spinal canal narrows and vertebrae become loose, which causes pain.
Each has their own
If the pain that has been treated with painkillers or ointments (pain-relieving gels), persist in two weeks, first of all, one should turn to the GP and still look for a possibility to have a specialist’s consultation.
Disc hernia is more common among young patients, which appears during physical exercise performance or due to an unfortunate turn. The pain is so strong that the patient cannot sleep at night, cannot find a comfortable position to decrease the pain.
A.Mertens reminds that the pain intensity can be very individual. “For some it seems that the pain is insignificant, but the problem is serious, and vice versa. But the most important thing is- whatever the pain intensity is, for each patient their problem is the most important. The doctor has to give a solution to everybody, which can be done only if the patient has come to the doctor.”
For people over 50 the back pain, radiating to the legs, most often is due to stenosis- narrowing of the spinal canal. One of the signs- the desire to sit down and relax on a bench during walks appears very quickly. If in the beginning it is not a problem to walk 500 metres non-stop, then later the distance decreases, and the wish to sit down appears after 300 metres, 100 or 50.
“Each disease and age has their own treatment techniques, mostly conservative ones with drugs. However, disc hernia can be treated well surgically,” adds the surgeon. The cut is up to two centimetres, the scar disappears in one year time, two to three days have to be spent in hospital and then the patient can go home. Improvements can be felt quickly. However, sparing lifestyle should be observed from six to eight weeks during the postoperative period. It wouldn’t be recommended to go straight back to work.
When treating stenosis to elderly people, a more modern technique can be applied- replacement of the damaged disc to an implant - an artificial disc.
Slowly and carefully
An active lifestyle will also be beneficial to spinal health. However, doing housework and walking to the shop will not be sufficient, regular training and classes are necessary. When meeting, e.g. Nordic walkers, and finding like-minded people and being more in fresh air, the stress level drops and other health promoting conditions appear.
“The biggest problem is then, when a human does not do anything and then suddenly decides to start a new life – runs some ten kilometres and on the next day is not able to move. It’s good that there is an intention to start a new life, but activities have to be taken up gradually. At first, under a coach, physiotherapist’s guidance, later it can be done regularly on their own the correct way,” Dr A. Mertens recommends.
It would be great if all intended activities were discussed with the coach or physiotherapist not to harm own spine, which often happens because the wrong exercise and load has been chosen. It is important not to exaggerate and to avoid rapid movements and remember to warm up before workout.
ADVICE FOR GOOD SPINAL HEALTH
* Watch the weight, for overweight is an extra load not only to the knee joints, but also the spine. Moreover, overweight makes it difficult to operate, if it is necessary.
* In case of acute pain the back has to be spared- stop doing exercise, workouts, don’t give a massage and don’t heat the place.
* Choose symmetrical types of sport- swimming, Nordic walking. Physical activities have to be done every day, remembering to exercise all muscle groups.
* Heavy things have to be lifted correctly – not bending, but squatting.
* In case of a chronic pain, one should see the specialist, for back pain confirms the pain in the spine, which has to be treated by a specialist.
Traumatologist orthopaedist AGRIS MERTENS
Even though the traumatologist orthopaedist AGRIS MERTENS had all opportunities to start a successful career in Rīga, he agreed to work for Liepāja Hospital and now he is considered to be one of the new spinal surgery stars. Patients from all over Latvia come to him. The doctor’s hands do real wonders- they have fixed tens of broken bones, giving people an ability to move freely.
A year and a half ago in Liepāja an operation was performed, about which the whole Latvia knew. For the first time, an operation, during which a damaged vertebra was fortified by implants from both sides, operating the patient through the chest and after that also in the back part. This operation was performed by the spinal surgeon of Traumatology and Orthopaedic Hospital Spinal Surgery Centre Artis Gulbis, but Agris Mertens assisted him. Now Agris performs lots of complicated and life changing surgeries himself.
- Why exactly the operation a year and a half ago was so important? What has been achieved so special during it?
- We started a new stream of operations in Liepāja with this kind of operation, when it is possible to do the surgery through the chest. Also it is possible to stabilize the spine in the chest with the so called jacks. Such operations had never been done in Liepāja before, as new skills were needed both form the surgeon and anaesthesiologist’s side. In surgery the same way as in life, everything has to be acquired gradually. A child first of all learns to crawl, then to walk, speak and only later to write. The same is in surgery. It is not possible to skip the crawling period and start writing at once. A surgeon starts with simple operations and not with cosmic manipulations.
Sometimes it happens when surgeons do an unprecedented operation and then everything finishes. There was one operation like that and never ever again. Whereas, now in Liepāja we do them regularly, even though initially it seemed- who will need such surgeries, there will be no patients like that. It’s just opposite, there are lots of patients and this year we have already performed four such operations.
- Can we say that with such an operation it is possible to fix a broken spine?
- Yes. Such operations are mostly performed when there is a fracture. In case of a fracture, the vertebra sags. It’s similar to a sagging house. If the “house” sags, the spine topples. During the operation we renew the height of the damaged vertebra, i.e. we insert something like a jack, which raises the “foundation of the house” or spinal vertebra to the former place, where it was before the fracture. The jack looks like a cone with small slabs or teeth at both ends. The teeth get pricked in the upper and lower vertebra, but the little pipes in the middle of the jack, when the jack is opened, slide over each other, raising the vertebra up to the right height and fixing it.
Most of the fractures happen just in the thoracic and lumbar transition part – TH12 and L1 vertebrae break. To operate on these vertebrae the surgery has to be performed through the chest. Why? Because the diaphragm is fixed on the level of these vertebrae, which separates the chest from the abdominal cavity. The best way to access the vertebra is from the chest side.
If the fractured vertebrae is lower and the support is necessary, then a similar surgery is performed, only in the lower part- the so called lumbothomy. I had a patient who had broken two vertebrae – as a result I had to perform two major surgeries.
- What is life like after this surgery?
- It depends. There are people with no complaints after the surgery. But there are people who complain about some discomfort, e.g. when doing some movements. One should be aware that after such a serious operation some small complaints could be. At the same time their quality of life is very good: the people are able to do all their daily things and they do not even have any restrictions. They can move freely and do sports. Only weightlifting should be avoided...
I should point out that the mentioned surgery and others are not only my own achievements. It is a serious teamwork which has been achieved purposefully and gradually. One of the biggest assets is that I have been lucky to work together with Dr Artis Gulbis. He is an outstanding professional doctor and an amazing person. All the operations I am performing now I have learnt from him. But we do not think of stopping, we keep learning, trying out new techniques, and thinking what new approaches could be introduced.
- You said that this has not been the only unique surgery, there have been also other surgeries.
- Yes. Once we did a surgery to a woman who had had a spinal trauma. Due to this trauma there appeared a fracture of the second vertebra bulge and it coalesced in a wrong way. The first vertebra anatomically differs from the other ones- it hasn’t got the vertebral body. It looks like a bagel visually. But the second vertebra, which is next to the first one, looks like a little cube with a spike. And this spike is stuck in the “bagel.” Thanks to this, we can turn our heads. In case of a trauma this spike or hinge breaks.
To repair the wrongly coalesced vertebra, we had to perform the surgery through the mouth, i.e. during the surgery the patient’s mouth is open, the tongue is pressed down and cutting the back wall of the throat, we can access the vertebra and mill it. However, extreme attention is required, as right behind this toothed bulge there is the spinal cord. If this is touched with the mill, extremely severe consequences can follow.
- Were your hands shaking then?
- No, not that time because Artis Gulbis did most of the work. But if surgeons perform surgeries daily, they get confidence in their abilities and skills, and they have everything under control. Thus there is no need for hands to shake.
Each operation needs a serious preparation. The fact that in Liepāja we have very good operative outcomes, proves that we have done a long and profound preparatory work.
We don’t do just heavy surgeries, we daily operate both disc hernia and spinal canal constrictions, etc.
I am really grateful to the Head of Liepāja Hospital Edvīns Strihs. From the very first day when I came here he has believed in me and supported me. I appreciate it highly. Yes, once I made a fuss in the Ministry of Health. As a result, the government gave us extra funding for nine surgeries in our department.
- Tell me, please, how did you become a doctor?
- I grew up in a wonderful family and I had a lovely childhood. My mom is an economist and she used to work for an architecture office. But my dad was a doctor. He worked for Experimental and Clinical Medicine Institute of Latvia University, my dad was the vice director. My dad was a scientist and together with the professor Jankovskis they both were especially interested in the osteoreflexotherapy area. Unfortunately, when I was fifteen, my dad died. However, I remember a lot what he taught me. My dad was a man with the capital letter. He had an incredible capacity for work- he worked from 6 o’clock in the morning till midnight almost every day. Also as a human being he was very generous and kind-hearted.
The relationships with my parents were always good – nobody ever scolded me, nor flogged me, we always agreed with each other. Moreover, I was pampered very much: nothing was denied, I could get everything I wanted to. When you have everything, you don’t need anything else. That is why both then and now I search for more spiritual than material values. Life is pretty short, so I want to develop myself during it as much as possible. My father encouraged me to develop continuously. He said the most important thing in life was to study, and study well, maybe better than the others, because an employer will always look for the best and most enthusiastic employees. So that’s why I am always trying to be the best and be among the best ones.
- It is usually said that parents and family shape a person. What qualities have you received from your family?
- As I have already said, the most important thing my family taught me was that a human being has to study. My parents taught me also to be active and sporty. Many years ago I started playing tennis, but in the secondary school I stopped it. However, now I have restarted it and this kind of sport gives me a huge enjoyment. Tennis gives me a chance to relax and it fulfils me.
We used to go skiing with my family in the winter. It was not possible to go abroad, that’s why we went skiing on Saules Hill in Krāslava. This year I did not manage to go to Davos, but last year and the year before I did it. When I was in a seminar in Davos, in the mornings and evenings I studied, but during the day I went skiing.
My dad worked a lot and he was always busy. However, I highly appreciate that he devoted one day a week only to the family. On Sundays we always went to museums, exhibitions, sometimes to the Zoo. My dad knew a lot about art, about different sciences and he often told me, my sister and mom about them. But after the visit to a museum we always went to a restaurant. It was a very good and happy time.
- Probably it is logical that you were influenced by your father to study at Medicine Department of Latvia University.
- It still wasn’t my dad’s, but my decision. Actually, my dad never encouraged me to become a doctor. When finishing Class 12, lots of my classmates wanted to go and study economics. But I wanted something more, to have a broader horizon. I understood it was only possible in medicine. Lots of teachers were my dad’s friends. One could think that because of that my study process was easier, but, in fact, it was just opposite- I had a tough time at university. Nobody gave me any discounts at university.
Of course, at first I did not know what specialization to choose. But everything happened the way it had to happen. When my dad died, we had slight financial problems in the family. Lots of thanks to my godfather who took care of our family. I also started to work as a doctor assistant in my free time from studies. My first salaries were 35,40 lats and for me it seemed a huge money.Later just by chance I started to work for Rīga Hospital No 1 in the Operative Block. Initially, I was interested in the abdominal or stomach surgery, but then I got interested in traumatology. Later I did some voluntary work at Traumatology and Orthopaedic Hospital. I was really lucky to work together with the leading specialists in Latvia. One of the doctors who has influenced me strongly is the traumatologist orthopaedist Didzis Kalns. I have learnt from him both human qualities and surgical tricks. Unfortunately, not long ago the doctor passed away.
Doctor Kalns taught me that surgery is not only mechanical work. One should also have style, aura and charisma. Thus internship is so important- the young ones can learn from the prominent surgeons not only the sleight-of- hand, not special surgeon’s tricks, but also how to present oneself, how to relate to work and patients.
It was just Dr Kalns who recommended me to be the trauma doctor on duty in Rīga Hospital No 1 during my internship time.
- If you had really wanted, you could have become the local star. But you left the capital city and went to the countryside. - I have no need to be a star, I want to be a high level specialist. What is the purpose of being a star who performs one surgery per year and during the rest of the time just enjoys the fame. I want that my work is approved, not my name.
We do great things every day, big articles could be written about them. But why do we have to do it, who needs it?
Why didn’t I stay in Rīga, but went to Liepāja? It happened like that… I did my training practice for three months with Professor Kristaps Keggi in the USA. When I came home, I received an offer to go to Liepāja City Council and the Career Days organized by Liepāja Regional Hospital. There was an offer to go to Liepāja by plane. I love flying! Of course, I agreed to go.
I knew Liepāja pretty well because my cousin lived there, whom I used to visit quite frequently. During one of my visits I found out the Dr Egils Deksnis had died and Liepāja Hospital was looking for a traumatologist. I was on holiday and I decided to earn some extra money during it and relax on the beach after work. The hospital accepted me and I worked there the whole summer. Leaving it, I received an offer to work for the hospital permanently and complete the internship there and move to Liepāja. I did not accept the offer because for me it was important to complete my internship in Rīga, where I had started it. But after the internship, I still returned to Liepāja Hospital, as I had promised.
- Didn’t you have any doubts about what you were doing? Some think that everything happens only in Riga.
- I have never any doubts about what I am doing. Once I have made a decision, I don’t doubt it. Everything is in illusions and the heads. I was absolutely sure I will be able to develop myself and my work in Liepāja. I knew I would be able to do great things. One has to look globally, on the world’s scale. What is Rīga in comparison with the world? Just a small dot on the map.
Everything depends on the person and their goals.
The fact that I am in Liepāja doesn’t mean I don’t see, don’t hear and don’t understand what’s going on somewhere else. There have been times, when I asked my colleagues to swap shifts because Dr Gulbis had invited me to assist him in a complex surgery and that’s why in an interesting surgery in Rīga. Then I also heard some comments like- why are you going, how much is petrol spent on it, what do you need it for? I replied- once it will pay back five times. And it is like that – everything that has been invested into education, pays back later many times in many ways - materially, emotionally and in terms of knowledge.
When I came to Liepāja and announced that I would start spinal surgery, lots of people thought who it was needed for, such operations hadn’t been performed for ten years and nobody needed them. But I don’t regret my determination- my list of appointments is full every week, surgeries take place every week.
- It’s safer for a young doctor to work under a more experienced colleague’s guidance. You were absolutely alone in Liepāja.
- Artis Gulbis backs me up. I can call him any time and ask for advice. But on the other hand, as there is nobody next to me who always teaches me, and shows me what to do, I have to be confident about myself what I do. I have to start the surgery and I have to complete it myself. I don’t have the term- I can’t. Why can’t? I am a surgeon. I am happy I have had such a school. When operating alone, also decisions have to be made on my own. It gives me a feeling that in the operating theatre you are like a captain, who manages the team- nurses, anaesthesiologist….. I have to concentrate on the surgery and at the same time control the situation around. At first it was very hard, so I wanted an assistant. But if there is not such a person, then I have to cope with everything myself. Now I think- I don’t even need an assistant. What is the assistant going to tell me- how to insert a screw? I can do it myself very well.
- What is your daily life like?
- One day a week is for patients’ appointments. The other days in the mornings we plan surgeries, but in the afternoons visits. I can say I do surgeries every day, and every other day a big, complex surgery.
For lots of patients the financial situation is not excellent, our society is not very wealthy. And the biggest problem is that less wealthy people are not so welcomed. My opinion is just opposite – I do operate on them. If a human being needs help, we cannot judge the person by money; have they it or not. The surgery has to be performed, and if necessary, a construction worth of several thousand lats has to be applied.
- Your specialization is spinal traumas. They say it’s the human centre. Unfortunately, on a daily basis this centre is being damaged on purpose or just by chance, e.g. sitting by a computer.
- None of us is protected from traumas. But we have to be aware that we ourselves pretty often challenge the traumas. For instance, doing extreme sports which have a high risk of traumas.
But, if we are talking about back pain, then the main fact to be observed is – be active, move a lot, try to do exercise. Ideally, go to the swimming-pool regularly or swim in a lake or the sea in the summer. However, heredity means a lot. I have patients, who do not have any problems with the spine, and I also have patients who are in their early forties, but it seems that worse can’t be. Therefore, if parents have had problems with the spine, then also their children should think about their lifestyle.
Spine is connected with the head both literally and figuratively. That’s why it is important to live in harmony, in balance. Quite often back pain is related to the stress- having several jobs, being in a hurry and trying not to miss something. But when the person comes home in the evening, there is a feeling that the back is killing. The tension level is high which causes the pain in the back.
The summer has started, that is why I would recommend to spend more time in nature together with the family, go for a swim. Not to sit for a long time – every half an hour, forty minutes stand up, go for a little walk and then again back to work. When doing this, not only the body will relax, but also the brain. If we live in harmony, then the back pain will also decrease. But if the pain does not decrease, then the doctor’s help is necessary- the cause of the pain has to be found out.
- A human being needs some energy charge to work hard.
- Recently my biggest passion is sport- I play tennis, usually together with my colleague Artis Gulbis and also with others. I am sure the time has to be spent together with the people you feel well and comfortably. All the people I play tennis with are kind-hearted, open and friendly.
I like that nowadays doctors’ opinions about the free time activities has changed dramatically. In the 90s there was a saying- what a surgeon you are if before the surgery you don’t take 50 grams of cognac. Today it is not like that. I don’t think a patient would be happy to meet a surgeon who smells of alcohol. In leisure time - maybe, but I am definitely not keen on it. I can feel well and freely also without any external stimulators.
- Lots of people think that the family - wife, children provide energy. You are single at the moment.
- I like girls very much and the most beautiful ones live in Latvia. However, I still have not found the very best and most beautiful, so I am not married yet. Of course, I have a dream about a family, wife, children and house. Up to now my job has taken very much time, there is no time left for my private life. But I do hope everything will happen, when it has to happen. The only thing I know for sure is – my wife has to be feminine, educated, and able to keep the family hearth, so that it is exciting to be with her together. Overall, I think the search for a wife is like a business project. The woman, who you are going to spend the rest of the life together with, has to be both the finance holder and children’s educator. Thus the confidence that you can rely on your partner is essential, and that your “business” is maintained. To achieve it, only long legs and blond hair are not sufficient…
- Have you got any weaknesses you would like to get rid of?
- The bad habit I would like to get rid of is – I am often late. Yes, in most cases my being late is objective: the surgery takes a longer time, more time needs to be spent on a patient. Sometimes I am late for the appointment even for an hour. Thanks a lot to my patients who are still waiting for me and are not angry with me. Whereas, I would like to learn a better time management. Even though I don’t know whether it is really possible- I have so much work and I want to help everyone.
Radiological examinations are very essential- radiography (X-rays), Computed
Tomography, Magnetic Resonance. Results of all previous examinations (pictures,
CDs, information access ID and password for the Internet browser). Description of
the examination without the visual information is not informative.
It is also highly recommended to take with you other examinations like blood tests, USG of the abdomen, if they have been done before, as well as the data about the previous consultations, treatment and records from hospital.
It is important to keep in mind that the previous examinations can help to set the right diagnosis.
All examinations have to be taken with you when coming to the appointment. The doctor will assess which ones are necessary and which ones are not.
If no examination results are available at home, please, turn to your GP to ask for help to get ready for the first appointment, to collect the previous examinations form the medical record case (anamnesis).
In case no examinations have been done, do not try to do them without the doctor’s prescription. During the first appointment the doctor will examine you and prescribe the necessary examinations.
It is recommended to think over and write down the list of main problems at home, as well as the taken medication.
In 2014 a serious reconstruction was accomplished in the hospital, due to which now patients are offered completely new medical premises and equipment providing medical services on the highest level. Operations of spinal surgeries have been performed at Liepāja Regional Hospital since 2009. More than 700 operations have been performed by now. Patients can receive complicated and expensive spinal surgery operations. Liepāja Regional Hospital offers state-funded surgeries, so that patients could afford such operations. A wide range of varying complexity operations are performed- starting from small , short operations like micro-discectomy, where the nerve root is released, which has been pressed with a herniated disc, without any implants, up to a large scale reconstructive operations with implants. During the years the staff have obtained profound experience, which guarantees the best outcomes for the patient.
Pre-operative check-ups are necessary for a successful surgery procedure – patients are examined more profoundly, blood tests are taken, ECG, X-rays, as well as the anaesthesiologist’s consultation before the surgery. The examinations are performed at Liepāja Regional Hospital two weeks before the operation. On the day of the surgery patients have to arrive with an empty stomach at 8am, bringing the spinal surgeon’s verdict, all medicines used daily, records from hospitals and doctors.
Surgeries are performed in Traumatology Department, where qualified medical staff
operate, whose main work goal is to provide patients with the highest level of health
care and comfort. On the day of the surgery neither food nor drinks are allowed –
patients should arrive with an empty stomach and all examination results,
sometimes corsets for the waist or the soft collar are needed during the post-
The operating theatres have just been built and equipped with the newest technologies, laminar light exchange systems which provide a safe and sterile environment for the patient, and LED lights. During the surgery the implants produced in Germany are applied- a high quality titan implants.
We offer both the special spine fixating screws and intervertebral disc implants. The
combination of these both elements creates the best post-operative results.
Most of the operations are the micro-discectomy operations, the goal of this operation is to decrease the pain which is due to a herniated disc when the nerve root is pressed. These operations have good results and patients on the second post- operative day can stand up and on the third day go home. Actually, patients immediately after the operation say that their complaints have totally disappeared. The operations have a quite low-risk probability. During the post-operative period the patient receives rehabilitation from a highly qualified staff from Rehabilitation Department. Patients are trained to do exercise, answers are given to unclear issues, and restrictions of the post-operative period are explained. On the day of the discharge from hospital the patient is issued a record where the post-operative directions are written down once again.