John Caruana came to the USC Spine Center looking for a second opinion about a proposed treatment for his chronic back pain.

The lifelong athlete underwent spinal fusion surgery in his late 20s to relieve pain he believes resulted from taking too many hits playing high school football and soccer at California State University, Dominguez Hills. Although that first procedure had been successful for 15 years, the pain returned in his early 40s. “I couldn’t even pick up my son without my back getting stiff,” said Caruana, now 49. “I felt like an old man.”

Another surgeon had proposed a second fusion, this time of the vertebra directly above the site of the original fusion. Recalling how long that first surgery sidelined him, Caruana wanted to be sure he was doing the right thing before agreeing to have spinal fusion surgery a second time.

As it turned out, the second opinion was a good idea. John Liu, professor of neurosurgery at the Keck School of Medicine of USC and co-director of the USC Spine Center, ordered a 36-inch X-ray, which revealed something Caruana’s first surgeon couldn’t see: He had flatback syndrome, meaning he had lost some of the natural curvature of his spine — possibly as a result of that long-ago spinal fusion.

Back pain is extremely common with so many causes that diagnosis can pose a challenge, noted Liu. The team at USC uses large X-rays to review the alignment of the spine. “Looking at the alignment is a newer concept and not everyone does it,” Liu explained. In Caruana’s case, it revealed important information and showed that the previously recommended surgery would not have ended his pain.

The team at the USC Spine Center typically assesses new patients and steers them to noninvasive treatments for back pain. Caruana had already tried physical therapy, acupuncture and years of core-strengthening exercises in the hope of avoiding a second surgery.

After hearing Liu’s diagnosis, as well as the fact that the Keck Medicine of USC team uses minimally invasive procedures, Caruana was convinced he would have a better result if he let Liu operate.

As the date of his surgery approached in April 2013, Caruana dreaded the recovery because he owns an auto body shop, and his hobbies include restoring cars and riding dirt bikes — activities that require a lot of movement and working with his hands.

“I don’t like the idea of not being able to do serious physical activity,” Caruana said.

Rather than make a large incision across Caruana’s side and back, which is the standard approach, Liu gained access to Caruana’s spine through several small incisions in the back through which he fused three vertebrae to restore the lost curvature, and re-plated Caruana’s first fusion.

The recovery Caruana dreaded turned out to be relatively short. He was back at work two weeks after his operation, and was in the gym working out two months later.

“I feel very fortunate to have found Dr. Liu. I feel like a young man again.”

By Hope Hamashige