Neurosurgeon Jayant Jagannathan conducts morning rounds several times a week on his patients at Garden City Hospital with Amy Tittle, a surgical nurse practitioner who assists with patients and surgeries.

But this time was different. He was with a Crain's reporter who had permission to take notes of doctor-patient interactions and later that day witnessed a spinal fusion surgery on Angela French, a school librarian who traveled with her husband, Dave, from the Michigan Thumb to have her painful back surgically repaired.

Jagannathan is one of two neurosurgeons at Garden City, a for-profit hospital owned by Prime Healthcare of California. The other is Y.S. Mohan, who also is on staff at eight-hospital Beaumont Health. A third doctor, orthopedic surgeon Stanley Lee in West Bloomfield Township, also performs back surgeries at the hospital.



"Last October, (Angela) began having severe pain. She had physical therapy and shots, but it wasn't helping. She works at a school and is on her feet constantly. It got worse. There was too much pain, so she asked me to do surgery," said Jagannathan, who has had an on-call contract at Garden City since 2015.

Jagannathan does a variety of minor procedures and major surgeries. One of the most common spine procedures in the U.S. is spinal fusion, which joins two or more vertebrae together to prevent movement to treat back pain and most often is done in the lumbar region of the lower back. More than 87 percent of spinal procedures are fusion-based, according to research firm GlobalData.

"We always give options for pain management, but they have already seen their primary doctor and tried options. It is fusion versus no fusion. Another option is a laminectomy (decompression surgery) where we shave off (the back part of a vertebra)" to enlarge the spinal canal to relieve pressure on the spinal cord or nerves, Jagannathan said.

In 2016, the global market for spinal fusion, which includes an array of medical devices, is projected to increase at an annual rate of 3.4 percent annually to $9 billion by 2023.

Those devices and other advancements have changed the back-surgery game. Before minimally invasive surgery began in the mid-1990s, Jagannathan said surgeons had to make 5-inch slices along the spine, and the hospital stay was much longer than one or two days now.

"The trend toward a minimally invasive approach will help this, as it usually results in a quicker recovery with less postoperative pain and shorter hospital stays," Jagannathan said. "These types of technologies will see increased prominence in smaller hospitals particularly."

But before French's surgery, which would start about noon, Jagannathan and Tittle had other work to do.

About 10 a.m. Jagannathan and Tittle began rounds of six patients, including three in intensive care.

Up first was a middle-aged man who was recovering from cervical disk fusion surgery from the day before. He was having some difficulty and was placed in the ICU.

"He has a clotting disorder that predisposed him to strokes and requires lifelong anticoagulation, but everything is normal today," Jagannathan said. After a few days in the hospital, he was discharged and is doing well.

Up next was an older woman who had a cardiac arrest at her home and was brought to the hospital by ambulance. She had strokes on both sides of the brain and was unconscious. Staff had placed a catheter in her brain to drain out the fluid. After a day the pressure was nearly normal because there was not much fluid left, but she was on a ventilator.

The third patient, an overweight man in his 40s, was alert and talking. He had come in the night before with a head injury from a mysterious fall.

"He has a vertebrae in his neck that is broken," Jagannathan said. "He will need an MRI and probably more tests to see if there are other problems. We don't want to discharge him and see him back with other problems."

The MRI showed significant ligamentous injury and narrowing around the spinal cord, which often causes people to lose their balance and fall. He was operated on for decompression and stabilization. Later, he was discharged to a rehabilitation facility to work on safe walking.

Next was a male patient in his 30s with his wife and three children in the room. He was preparing to have spinal fusion surgery.

As Jagannathan and Tittle entered, the man's face lit up. "I have complete faith in you. You come highly recommended," said the patient, who previously had an unsuccessful spine surgery in Colorado, where he use to live.

Jagannathan smiled, explaining to the patient that he had several misplaced screws from the previous surgery that needed fixing and also a calcified disk pushing up on his thoracic spine. "I will move up the screws you have and put two new ones in," he said.

The patient said he had planned to get a thoracotomy to remove the disk at another large Detroit hospital, but canceled it because he said he didn't feel comfortable with the surgeon.

"I admit I am scared about this," the patient said. His wife added: "He is afraid he won't wake up." Jagannathan told him not to worry and that they would take good care of him.

After a successful surgery and a three-day stay, he was discharged. Several weeks after the surgery he was doing well, although it will take several months of limited lifting and bending before he can return to work.

The fifth patient was a young, active man who previously had spinal fusion surgery at a large suburban hospital. The surgery apparently was successful, but the patient had reinjured himself because he did not properly rehab and use his back brace.

"We removed and replaced the cage (that enlarges the space between vertebraes)," Jagannathan said. "He was discharged home that day and is doing better."

Last, an older woman who had fallen, hit her head and experienced a traumatic brain injury. She was admitted through the ER and was in the long-term care section of the hospital. She had a small head bleed that developed into a larger bleed that was causing pressure on her brain.

She had been in the hospital for three weeks, and surgeons decided to do a 2 1/2-hour emergency decompressive operation. The surgery would relieve pressure on her brain by peeling back her skull cap.

"The CT scan looks good. We will give her medicine and follow the protocol. It likely will take several months before the skull is replaced," said Jagannathan, adding that the outcome is unknown.

The approximate 600-square-foot surgery room was filled with equipment and staff when French entered one of the eight ORs at Garden City.

"They wheeled me in," French said in an interview two weeks after her surgery. "It was the first time I saw a surgery room. I was kind of surprised how small the room was. I was face down. They were putting those little needles in my leg. They told me it was for testing on nerves. They put on the gas mask, and I don't remember anything more until the recovery room."

Scrubbed in and wearing blue surgical gowns were Jagannathan, who also wore his signature Washington Redskins football skullcap; Tittle; anesthesiologist Keshav Joshi; a neuro-monitor technician; an X-ray technician and two other nurses. Two medical representatives were also present, John DeLeon with Globus Medical in Philadelphia and Dan Rosario with Aegis Spine of Colorado. They were there to answer any questions about the devices to be inserted during surgery.

Rosario explained that the spacing between French's vertebrae were too small, and Jagannathan planned to insert several expandable spinal "cages" to restore the height between vertebraes that were squeezing and placing pressure on the nerves, causing pain.

"They go in small and crank up to larger height which allows us to open up the disk," Jagannathan said. "Expandable is new technology. By going in at a small size there is less risk of injury to surrounding nerves, but they can still expand once in."

Once everyone appeared ready, one of the nurses began calling out information on the patient and the surgery plan for the operation on the left side, L5-S1, or the lumbar region's fifth and lowest vertebrae. French's L5-S1 had slipped over the first vertebrae of the sacrum. Everyone concurred with the plan.

"You are seeing minimally invasive surgery from three different (measuring perspectives)," Jagannathan said.

The first view is Jagannathan's own as he is conducting the surgery. The second view is the intraoperative imaging that continuously displays the surgical instruments and implants on a high-resolution screen for the surgeon and team to monitor. This allows the surgeon to view live feedback and ensure the most precise implant placement. The third view is the neurology monitoring that tells the team how the nerves are responding in real time.

"This allows a system of checks and balances," he said. "When you make moves around the brain and spine, all three parameters must correspond to be safe."

Because the surgery is minimally invasive, the surgeon can make much smaller incisions along the spine. This reduces post-surgical pain, scarring and blood loss, leading to fewer complications and a faster recovery, DeLeon said.

"We use imaging to locate where (the spinal) screws enter. By doing this, we can make tiny incisions to implant the screws," said Jagannathan, explaining the instrument has a guide wire that helps to locate and verify placement of the screws.

After 45 minutes, the four spinal screws are inserted. Jagannathan now put on large magnifier glasses for better vision. He takes up a shaver instrument that sounds like a dental drill to remove the disk cartilage and bulge. French cannot hear it because she is out under anesthesia. The point is to decompress the vertebrae and make room for the expandable cages.

"Now we are putting in the cages in L5-S1 to open up the space," Jagannathan said. He then inserts the cage, places bone grafts into the cage to promote healing, and then places pins on each side to secure it. This takes another 30 minutes. He cranks open the cages to the maximum, locks them in, then places rods on each side of the cages, which are attached to the screws.

DeLeon said the cages can be expanded between seven to 17 centimeters, depending on what the surgeon wants. Over time, the two vertebrae segments will heal, and then bone grows around it and fuses over eight to 12 months, Rosario said.

Several times during the two-hour surgery, Jagannathan asks if everything looks clear on the neurology monitor. Probe sensors are placed on the skin that sends electrical signals if there are problems with pinching in the muscles.

"They have real-time nerve readings which are interpreted by a neurologist who is off site," Jagannathan said. "This is why I continuously ask for updates during critical parts of the case. Some nerves are sensitive, and even minor trauma can injure them. There have been cases where I have had to change our plan due to neuro monitoring."

"She had degeneration on the disks. We got the height of the disk back to normal. Everything went well. She should get up this afternoon and go home tomorrow," he said.

For 22 years, French, 47, has worked at Croswell Lexington Community Schools. Always an active woman, last fall French hurt her back trying to shoot an arrow. She pulled the bow back and felt a pain along her spine.

"I woke up the next morning, and it didn't feel good. It was manageable until the beginning of April," she said. But she and husband, Dave, took a trip to Florida, driving 24 hours. "It became very painful."

French came home to Michigan and went to see a chiropractor that same day. "I did some traction where they stretched out my body by pulling my legs. It caused me so much pain I couldn't get out of bed. I went two weeks of three sessions a week, and the pain was even worse," she said.

She then went to see an orthopedic surgeon in Port Huron underwent an MRI and found she had a herniated disk that was pushing on the sciatic nerve. She was given oral steroids and then an epidural injection for the pain. "It got worse, not better. He wanted to do another epidural and then consult with their surgeon about a laminectomy (decompression surgery)," she said.

As she talked with people about the surgery, her sister-in-law, Kari Stoutmeyer, told her how she had a spinal fusion surgery done by Jagannathan. Stoutmeyer already had a laminectomy but told French that was just a "Band-Aid" and the real fix for her was the spinal fusion performed by Jagannathan.

"I called him, saw him in a week and had surgery a week later. I had a sharp pain down my left leg. I had drop foot. It was so numb, I was dragging it along with me and couldn't walk straight," she said.

Asked if she was referred to physical therapy before surgery and she said she was past the point where that might help. "Anything I did caused more and more pain. My doctor said rest it, just stop moving and rest."

French said her Blue Cross Blue Shield of Michigan policy covered everything, including the previous chiropractic treatment and pain therapy. She had already met her deductible for the year because of her prior medical treatments. She also didn't have any copayments for the hospital or physician services.

"My insurance also covered my back brace and a nurse that came to my home after surgery," French said. The total hospital and physician bill for surgery was $113,000, but Blue Cross only paid about $38,000 after provider discounts, French said.

After her surgery, French said the first thing she remembers is Dave waiting for her to wake up by her bed.

"I had to take two nights (Wednesday and Thursday at the hospital). Dr. Jag said I could go home the next day, but he suggested I stay another night because I was still very nauseous because of the anesthesia. I was bad. I couldn't keep food down. I know I have problems with it. They gave me dopamine, and I came home Friday."

But after 12 days in recovery, French said she is outside walking and doesn't have any pain in her back or leg when just a ride to the doctor's office caused her to "cry the whole way there."

French said she took only a few Percocet in the hospital and regular Tylenol at home. "I had the staples from the surgery taken out" after two weeks. "They just popped them right out," she said.

Her rehabilitation over the first several weeks consisted of a visiting nurse coming to the house, and later physical and occupational therapy sessions.

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"It is summer. We don't have school, so I am just resting," she said. "In three months I will do physical therapy to strengthen my core. I just want to get back to my normal life. We have 10 acres of land I want to get back to mowing and gardening."

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