Surgeon performs unique surgery
By JEAN ORTIZ courtesy of the Associated Press appearing in the Lincoln Journal Star 6/7/2004
OMAHA - At age 30, Anna Lundmark is as fearless as they come. Some people also might call her lucky.
The former competitive skier once hit a tree while traveling 45 mph. A few years later, she landed on her head after flipping off a jump.
After 14 years of suffering from chronic debilitating back and neck pain, the Stockholm woman took a new risk - a procedure offered by Dr. Ake Nystrom, a fellow Swede and a surgeon at the University of Nebraska Medical Center.
The procedure is aimed at easing pain for people suffering from whiplash and similar neck and upper back trauma.
But experts in pain management and related fields say they are skeptical about the procedure, which is believed to be done on a regular basis only by Nystrom.
"On the surface it sounds a bit outrageous, but one can't categorically say there isn't anything to it," said Dr. James Campbell, a neurosurgeon and pain specialist at Johns Hopkins Hospital in Baltimore.
During the three-hour procedure, the patient is awakened after a vertical incision is made on the back of his or her neck. Patients don a sterile glove to reach into the wound and point out pain points in their upper back and neck.
Nystrom then cuts away the connective tissue from the nerve at that site. He said he must work slowly, and carefully, since the wound is not anesthetized. Nystrom said he needs patients to be able to differentiate between their old pain and pain they would be feeling from the surgery.
Two months after the unique form of trigger-point surgery, Lundmark says she had the same results she did the week following surgery - a normal range of motion and minimal pain in her neck. That's a change for a woman who once took six prescription pain pills a day, was forced out of competitive skiing and could turn her head at most a few degrees to each side.
"It's like a miracle - it's amazing," she said.
Campbell said it is difficult to gather reliable data in the pain field because of a possible placebo effect.
Dr. David Apple - an orthopedic surgeon and medical director of Atlanta's Shepherd Center, which specializes in pain management - shared Campbell's sentiments.
"If a patient thinks you're doing something that is going to help them, the mind over matter sort of takes over," Apple said.
"It's sort of an old adage - you can't cut out pain," he added.
Both Campbell and Apple say more structured research is needed to better understand the procedure's level of effectiveness.
Nystrom's patients undergo tests to their range of motion once before and once after the procedure, said Dr. Glen Ginsburg, medical director of the Munroe-Meyer Institute at UNMC, who helps conduct the tests.
"Every patient is statistically significantly better," Ginsburg said.
Nystrom has been at the medical center since 2001. He came to the United States in 1994 and performed several hundred of the surgeries at the University of Pittsburgh, he said.
Most of Nystrom's patients are Swedish, something Nystrom attributes to heavy media attention in Sweden.
He doesn't actively pursue those patients, he said.
In 15 years, Nystrom has seen more than 600 patients for the surgery, though it didn't become his focus until the mid- to late '90s, he said.
Nystrom plans follow-up testing for some of the patients. Such testing has been hampered because of the large number of international patients, he said.
Nystrom has no plan to use an independent researcher to study the surgery - something that Campbell said is important in validating Nystrom's findings.
But Nystrom said he is open to the idea if someone expressed interest.
Some medical insurance plans have covered the procedure, although a majority of Nystrom's overseas patients pay for the procedure - generally between $15,000 and $17,000 - themselves, he said.
Celann LaGreca, a spokeswoman with Blue Cross and Blue Shield of Nebraska, said the company is reviewing the procedure before deciding whether to begin granting patient coverage requests.
Why the surgery appears to be working is unknown, Nystrom said.
"I don't know that any better than anyone knows why operating on a tennis elbow relieves pain, and no one knows that," he said.
Campbell said sometimes surgeons discover the rationale after getting an idea and finding that it works.
"But for every one of those ideas there are 99 where it just ends up being snake oil," he said.
A car accident several years ago left Nina Andersson, 36, also of Stockholm, to deal with whiplash and pain that radiated into her arm, leaving her fingers numb. She was referred to Nystrom after seeing a hand surgeon in Sweden.
After the surgery, Andersson said she immediately noticed her pain was gone and tried to refuse the standard wheelchair ride out of recovery.
Martina Johansson, 28, who lives just outside Stockholm, said her mother read about the procedure in a Swedish women's magazine. Johansson, who had been suffering since a 1998 car accident, said she had a few friends who tried to change her mind about having the surgery.
"I think it is difficult for anyone without chronic pain to understand that you have to take the chance," she said in an e-mail.
Thirty hours after her August 2002 surgery, Johansson drove across the country on vacation. Today, she is back in Sweden, where she works as an engineer and has not relapsed, she said.
Nystrom recommends patients rest following the surgery. He says therapy usually is not needed.
He emphasizes that the procedure is not a cure-all. Like any surgery, there are risks, he said.
Lundmark had two hematomas, or collections of blood, in her back that were drained within days of the surgery. She was the only of his patients to have such a condition, and Nystrom said he suspects she has a blood-clotting disorder unrelated to the surgery.
He said it's good that there are skeptics out there, but he stands behind the procedure and its ability to give people their lives back.
"What we do is not experimental surgery. We provide routine health care and we do that rather successfully," he said.
Awake on the operating table -- Unique procedure for chronic, debilitating pain from whiplash helps patients for whom all other treatments have failed.
More than 80 percent of patients say their pain is eliminated or significantly reduced post-surgery
By Karen Burbach, UNMC Public Affairs
Patients with chronic, debilitating pain from whiplash and other trauma are turning to the University of Nebraska Medical Center/The Nebraska Medical Center ("UNMC"), and a unique surgical treatment program that enables them to recapture their lives. 
Unlike traditional surgery, however, these patients are only partially sedated during certain portions of the surgery. UNMC’s renowned surgeon, Ake Nystrom, M.D, Ph.D., says patient participation is vital to the success of the procedure. Pain, he said, is not a visible symptom and radiographic imaging or tests of nerve conduction don’t always give an adequate assessment of pain or its focal origin. So, Dr. Nystrom relies on the patient’s input to identify the pain-producing "trigger" points in the fascia (connective tissue around the muscle) that need to be removed.
Using mild sedation intermittently during the surgery, and with the help of the patient, Dr. Nystrom isolates possible areas of discomfort and removes the nerve "trigger" points in the fascia. A skilled anesthesia team is critical for a successful outcome. Patients receive ultra-short acting anesthesia, compared to traditional anesthesia that may leave a person groggy 30 minutes after surgery. Patients need to be clear-headed to help guide the surgery and point out the exact location of their pain. If their pain is too great, or sedation too deep, they can’t differentiate between “old” pain and “new” pain caused by surgery. 
During the past nine years, Dr. Nystrom has performed trigger point surgery on 600 patients with whiplash, including, Ulf Johansson. After a whiplash injury in 1996, he was unable to work or sleep restfully for seven years. More than 15,000 prescribed pain pills, physical therapy and extended rest did not provide significant relief. 
Johansson made the 6,000-mile journey to Omaha for treatment for debilitating pain in his head, neck and arms. Three days after surgery, Johansson went pheasant hunting without any of the pain that had so severely deteriorated his quality of life.
Another patient, Therese Jonsson, an 18-year-old whiplash patient from Stockholm, said, “Doctors told me I would have to live with the pain for the rest of my life.” Then, she learned about Dr. Nystrom's unique procedures. “It’s amazing,” said Jonsson, who went sightseeing only one day after surgery. “I’m so used to living with pain 24 hours a day, that I’m just enjoying my time being pain free.” Said her mother, Yvonne: “It’s a miracle -- no more, no less.” 
Despite being awake for portions of the operation, most say they would undergo the procedure again in a heartbeat. “If your life is miserable to the point that you lose your desire to live, you’re much more willing to experience some pain for a reasonable chance to eliminate a significant part of the old pain,” Dr. Nystrom said. Patients agree, saying the pain experienced during surgery is short-lived and insignificant compared to the daily constant and debilitating pain they have endured.
The typical whiplash patient also sees a significant increase in neck mobility, better muscle strength and improved sleep. The procedure even helps many patients for whom all other treatments have failed. Whiplash affects a large number of people worldwide. It is more common in females and is often the result of trauma. To be eligible for surgery, patients must have had chronic, debilitating pain for more than a year, and must have undergone evaluations by a spinal surgeon, orthopedic surgeon or neurosurgeon to eliminate explanations for their pain that would be addressed with more conventional therapy or surgery. Dr. Nystrom’s patients have ranged in age from 18 to 70. He typically operates on one to two international patients per week, in addition to his American patients.
The Nebraska Medical Center’s culturally sensitive international department greets patients at the airport and coordinates all aspects of patient's care, including appointments, translations, travel, accommodation, billing, and keeping the referring physician updated. The department also arranges for dinning, site-seeing, shopping and other concierge type services.
Additional information: +1 (402) 559-3656, www.unmc.edu/international or e-mail: nmamdani@nebraskamed.com.