Minimally Invasive Spine Surgery
Minimally invasive surgery (MIS) spinal fusion can now be done using two small poke-hole incisions with minimal dissection, blood loss, and less pain, resulting in faster recovery than traditional open spinal surgery. With traditional spinal surgery, it is necessary to cut through muscles and pull them out of the way to reach the spine. Causing a large amount of pain and blood loss also lengthens recovery. By gently spreading through the muscles, the MIS technique allows us to reach the spine with less pain and blood loss.
A Transforaminal Lumbar Interbody Fusion (TLIF) is the most common procedure using the MIS technique. The MIS TLIF is commonly performed for many spinal conditions, including herniated disks, spondylolisthesis, and degenerative disc disease. An MIS TLIF involves relieving back and leg pain by removing any pressure on the nerve along with removing the disk. The disk is then replaced with a bone graft spacer, through which the vertebrae will fuse. Small screws connected by rods are also inserted, holding the spacer in place to allow fusion to occur.
There are several advantages to MIS, the greatest of which is less damage to surrounding tissues. In fact, there is rarely a need for a blood transfusion. Hospital stays are usually shorter, and there is often less need for narcotic pain medications. Most patients are up and walking within an hour of the procedure and can go home the same day.
Anterior Cervical Fusion
Anterior cervical spinal fusion surgeries are commonly performed in conjunction with an anterior cervical discectomy. For many patients, cervical spinal fusion surgery (fusing one vertebra to another) is often to eliminate motion at a vertebral segment. Decreasing the motion at a painful motion segment should decrease the pain at that segment. Achieving the fusion also maintains adequate space for the decompressed spinal cord and/or nerve roots. The fusion may also prevent the spine from falling into a collapsed deformity (kyphosis).
These surgeries can also help treat cervical instability due to trauma (fractures or dislocations), tumors, infections, and bone grafts for spinal fusion.
To achieve a spinal fusion, a bone graft helps promote two bones growing together into one. The patient’s bone will grow into and around the bone graft and incorporate the grafted bone as its own. This process creates one continuous bone surface and eliminates motion at the fused joint. A small piece of bone then helps fuse a disc space, while a longer strut graft is used to bridge across multiple disc spaces. This occurs only if you experience a corpectomy.
Treatment for scoliosis is based on the patient’s skeletal maturity (expectations of growth and degree of curvature). The younger the patient and bigger the curve, the more likely the curve is to progress. For patients with idiopathic scoliosis, the main treatment options are observation, bracing, and surgery. Other forms of treatment include electrical stimulation, physical therapy, and various manual manipulation techniques, but none are as effective.
- The degree of curvature is measured on X-rays by what is known as the Cobb method, which is accurate within 3 to 5 degrees.
- In cases of curves less than 10 degrees, there is very little chance of the condition getting any worse. In fact, this condition is known as spinal asymmetry rather than scoliosis. Most of the time, these cases will not require any treatment. However, the physician should check the spine regularly throughout the patient’s childhood to determine whether the curvature has progressed.
- Curves of 20 to 30 degrees in a growing child should be monitored every four to six months to check for worsening. Any curves over 30 degrees in a growing child will require treatment, usually in the form of a back brace. Using a brace is intended to stop the growth of a curve but will not correct the degree of curvature that already exists. The brace is no longer effective when the child stops growing.
- Curves greater than 50 degrees will sometimes continue to progress after the child has stopped growing. Therefore, the objective of any treatment is to get the child into adulthood with less than 50 degrees of curvature.
- There are two types of common braces. One is for most of the day and night, but can be taken off for swimming or playing sports. This brace applies three-point pressure and prevents the progression of the curvature. The other, which should be worn while sleeping, applies more pressure and bends the child against the curve.
- Unfortunately, some curves continue to progress even with appropriate bracing. This may lead to needing more aggressive surgical treatment. In some cases, the physician will continue bracing the spine for a period of time, allowing the child to grow more before performing surgery to fuse the spine.
- For patients with a curve of 40 to 45 degrees that is still progressing or a curve of 50 degrees or more, surgery is recommended. The objective is to fuse the spine into a more corrected position, so the curve will not continue to progress into adulthood. In addition to preventing further curvature, scoliosis surgery can also reduce the amount of deformity.
- Rods, cables, screws, and hooks are used to move the spine back into the proper position. When the spine fuses with the bone grafts, it no longer moves out of place. Although the rods can be removed once the spine has fused, there is usually no reason to do so. A correction of about 50% can usually be obtained with this method.
- Patients should be monitored regularly for the first year or two after surgery. Once the bone is solidly together, there is no need for further treatment. In general, patients can return to their normal lifestyle and activity level.
Scheuermann’s disease is a developmental disorder that causes patients to become stooped forward with a bent-over posture as a result of excessive kyphosis of the thoracic spine. The condition affects between 0.5% and 8% of the general population and is more common in boys than girls.
- Differentiating Scheuermann’s kyphosis from postural kyphosis requires a physical examination and radiographs of the spine. The physical examination determines where the apex of the curve is located, where the patient is experiencing back pain, how flexible the curve is, and whether there are any other related findings. Radiographs look for the presence of at least 5 degrees of vertebral body wedging over 3 adjacent levels (currently the most commonly accepted criteria for radiographic diagnosis). They also determine more precisely the relative percent correction possible by attempting to reverse the kyphotic curve with a bolster or pillow placed at its apex while the patient is lying down.
- The treatment of Scheuermann’s disease depends upon several factors, including the age of the patient, the severity of the curve, the presence or absence of back pain, and whether or not the lungs are developing and functioning normally.
- If a patient is young and has a mild curve, no back pain, and normal pulmonary function, then continued observation by a doctor is usually prescribed, with repeat clinical examinations and radiographs at regular intervals (often every year).
- Patients with kyphosis are often advised to participate in activities that strengthen the muscles supporting the spine. Stretching the hamstrings and improving cardiovascular fitness are also recommended. This type of therapy is considered an important part of ensuring the curve stays as flexible as possible to prevent further progression.
- Other forms of treatment, including bracing and surgery, are considered when there is a rapid increase in the size of the curve, worsening of the vertebrae body wedging, back pain that will not improve with conservative measures, or difficulties with pulmonary function related to the kyphotic deformity. The decision about when and how to brace the spine of a patient with Scheuermann’s disease, or perform surgery, depends on the individual patient.
A lumbar microdiscectomy is an operation on the lumbar spine performed by utilizing a surgical microscope and microsurgical techniques. The procedure requires only a very small incision and will remove only that portion of a ruptured disc pinching one or more spinal nerve roots. Recovery time is usually much less than is required for traditional lumbar surgery.
In general, lumbar microdiscectomy is recommended when a ruptured disc is pinching one or more spinal nerve roots and a patient is experiencing leg pain, weakness in legs or feet, numbness in extremities, and impaired bladder and/or bowel function.
Guided by the microscope, the surgeon will remove a small portion of bony material from the vertebra. Once this material is removed, the surgeon can locate the exact area where the nerve root is being pinched and determine the extent of the pressure on the nerve.
Using microsurgical procedures, the surgeon will remove the ruptured portion of the disc and any fragments that have broken off from the main disc. The amount of work required to complete the microdiscectomy will depend on the number of disc fragments present and the difficulty in finding and removing them.
Posterior Cervical Microdiscectomy
Some spinal surgeons may prefer the posterior approach (from the back of the neck) for a cervical discectomy. This approach is often considered for large soft disc herniation that are lateral to (to the side of) the spinal cord.
The principal advantage of the posterior approach is that a spine fusion is not required after removing the disc. The principal disadvantage is that the disc space cannot be opened with a bone graft to give more space to the nerve root as it exits the spine. Also, since the posterior approach leaves most of the disc in place, there is a small chance (3% to 5%) that disc herniation may reoccur in the future.
After a small incision in the midline of the back of the neck, the paraspinal muscles are elevated off the spinal level to be approached. An X-ray is then done to confirm the surgeon is at the correct level of the spine. For disc removal, a high-speed burr is used to remove some of the facet joints so the nerve root can be identified. A surgical microscope is then used for better visualization. The disc will be directly under the nerve root, which needs to be gently mobilized (moved to the side) in order to free up the disc herniation.
- Spinal fusion surgery is designed to stop the motion of a painful vertebral segment, which should decrease the pain generated from the joint. All lumbar spinal fusion surgery involves adding a bone graft to an area of the spine. This sets up a biological response causing the bone graft to grow between two vertebral elements, stopping the motion at that segment.
- Abnormal and excessive motion at a vertebral segment may result in pain for patients with degenerative disc disease and isthmus, degenerative or postlaminectomy spondylolisthesis. Other conditions that may be treated by spinal fusion surgery include a weak or unstable spine (caused by infections or tumors), fractures, scoliosis, or deformity.
How Revision Spinal Surgery Works
- At each level of the spine, there is a disc space in the front and paired facet joints in the back. Working together, these structures define a motion segment and permit multiple degrees of motion.
- A spine fusion surgery involves using bone grafts to cause two vertebral bodies to grow together into one long bone. This is known as a one-level spine fusion. The bone graft can be taken from the patient’s hip (autograft bone) during the spine fusion surgery or harvested from cadaver bone (allograft bone). Synthetic bone graft substitutes are also in development, and one bone type called morphogenic proteins (which helps the body create bone) is currently being used for certain fusion procedures.
- In general, lumbar spinal fusion surgery is most effective for conditions involving only one vertebral segment. Most patients will not notice any limitation in motion after a one-level spine fusion. Only in rare cases should a three-level (or more) fusion surgery be considered for pain alone—although it may be necessary in cases of scoliosis and lumbar deformity.
- When necessary, fusing two segments of the spine may be a reasonable option for the treatment of pain. However, a spinal fusion of more than two segments is unlikely to provide pain relief because it eliminates too much of the normal motion in the lower back and places too much stress across the remaining joints.
(TLIF) Trans. Lumbar Interbody Fusion
Transforaminal Lumbar Interbody Fusion (TLIF) is an operation where the lumbar spine is approached from the side through an incision in the back. A portion of bone and disc is removed from the spine and replaced with an implant inserted into the disc space. Titanium or stainless steel screws and rods are inserted into the spine to ensure the stability of the entire construct.
Patients suffering from back and/or leg pain are potential candidates for the TLIF procedure. The causes of the pain may range from natural degeneration of the disc space to some traumatic event.
The operation is performed with the patient lying on his or her stomach. An incision is made in the patient’s back to allow the surgeon access to the spine. Once the spine is in view, the surgeon removes a portion of bone from the appropriate areas of the spine, allowing for access to the disc space. The surgeon removes the disc material and inserts an implant into the disc space. The surgeon will also insert titanium or stainless steel implants into the spine to help restore the spine to its normal anatomic condition.
Patients will normally stay in the hospital for three to five days after surgery, depending on each patient and his or her surgeon’s post-operative surgical plan. Patients are usually up and walking by the end of the first day after surgery. Tailored recovery and exercise plans are provided to help patients return to normal life as soon as possible.
Cervical Disc Replacement
Artificial cervical disc technologies are being developed to treat symptomatic degenerative disc disease more effectively. The primary goals are to maintain spinal motion following anterior discectomy, reduce the incidence of degeneration of adjacent disc levels of the spine (adjacent-segment disease) and facilitate a more rapid return to normal activity.
- Cervical surgery relieves pain by restoring the normal spacing between discs. The standard procedure for disc replacement is an anterior approach (from the front) to the cervical spine. It is the same method as a discectomy and fusion operation.
- The affected disc is completely removed, including any impinging disc fragments or bone spurs. The disc space is distracted (kept open) to its prior normal disc height to help relieve pressure on the nerves. This is important as a disc typically shrinks in height when worn out, which can contribute to pinched nerves and neck pain. Guided by X-rays or fluoroscopy, the surgeon then implants the artificial disc device into the prepared disc space.
- Postoperatively, the patient can typically go home within 24 to 48 hours with minimal activity limitations.
Lumbar Disc Replacement
While there have been significant advances in devices and techniques for spinal fusion surgery, the procedure does not always work reliably. For example, in a review of 4,454 patients in 78 reports, Bono and Lee found the average fusion rate was 85%, and the average clinical success rate (pain reduction) was 75%. It was also determined that a successful spinal fusion takes a relatively long time (3 to 24 months with an average of 15 months) for healing and recuperation and causes adverse effects on adjacent levels over time.
Additionally, Transition Syndrome (premature degeneration at adjacent levels of the spine) remains one of the more vexing problems for spinal surgeons when advising relatively young people to consider fusion surgery.
But with the wide range of new products, procedures, and techniques currently in development to enhance spine surgery, many physicians see real promise for significantly improving standard care for patients.
This is especially true when it comes to artificial disc technology. In fact, recently published data from the Charite trial, as well as interim comparative data from the larger ProDisc investigational study centers, demonstrate improved VAS and Oswestry functional scores in arthroplasty patients and suggest an earlier return to work, with better lumbar motion, as compared to the control fusion group.
The procedure for a bone that needs to be surgically cut or broken is called an osteotomy. In the spine, an osteotomy is sometimes performed to create motion between segments in order to correct a deformity. It may also be performed to remove a block of bone that obstructs the spinal canal or prevents clear visualization of nerves or other structures around the spine.
Interventional Pain Management
To help manage pain for patients, the following interventional procedures can be performed:
- Electromyography and Nerve Conduction Studies (EMG/NCS)
- Epidural Injections
- Selective Spinal Nerve Root Blocks
- Lumbar Facet Joint Injections
- Medial Branch Block Injections
- Radiofrequency Nerve Neurotomy Procedures
- Lumbar Discogram Procedure
- Spinal Cord Stimulator Trial Procedures
- Sympathetic Blocks
- Sacroiliac Joint Injections
- Piriformis Muscle Injections
Epidural Steroid Injections
The use of spinal injections to treat low back was first documented in 1901. Then in 1952, epidural steroid injections were introduced for low back pain with associated sciatica (pain in the sciatic nerve due to lumbar disc herniation). Today, epidural steroid injections are integral to the non-surgical management of low back pain.
Several common conditions, including lumbar disc herniation, degenerative disc disease, and lumbar spinal stenosis, can cause severe acute or chronic low back pain and/or leg pain. For these and other conditions, an epidural steroid injection may be an effective non-surgical treatment option. While the effects of the injection tend to be temporary (relief from pain for one week up to one year), an epidural can be very beneficial for patients during an episode of severe back pain and provide enough relief to allow the patient to progress with their rehabilitation program.
An epidural is an injection that delivers steroids directly into the epidural space within the spine. This space is between the dura mater (a membrane) and the vertebral wall and is filled with fat and small blood vessels. It is located just outside the dural sac, which surrounds the nerve roots and cerebrospinal fluid (the fluid nerve roots are bathed in). Sometimes a flushing solution (either lidocaine or normal saline) is also used to help flush out inflammatory proteins, which may be the source of pain.
The procedure usually takes between 15 and 30 minutes, with the patient lying flat on their abdomen on an X-ray table. The skin is numbed with lidocaine prior to the injection. Then, using fluoroscopy for guidance, the physician directs a needle toward the epidural space. Once the needle is in the exact position, the epidural steroid solution is injected. The patient is then monitored for 15 to 20 minutes before being discharged.
Sacroiliac Joint Pain
Do You Have SI Joint Pain?
The SI joint can be a significant cause of lower back pain. Clinical publications have identified the SI joint as a pain generator in 15-30% of chronic lower back pain patients.1-4 In addition, the SI joint is a pain generator in up to 43% of patients with continued or new onset lower back pain after a lumbar fusion.
Sacroiliac Joint (SI Joint) Anatomy
The sacroiliac joint (SI joint) is located in the pelvis; it links the iliac bones (pelvis) to the sacrum (lowest part of the spine above the tailbone). It is an essential component for energy transfer between the legs and the torso.
Like any other joint in the body, the SI joint can be injured and/or undergo degeneration. When this happens, people can feel pain in their buttocks and sometimes in the lower back, hips, and legs. This is especially true while lifting, running, walking, or even lying on the involved side.
It’s common for pain from the SI joint to feel like disc or lower back pain, or sometimes hip or groin pain. For this reason, SI joint disorders should always be considered in lower back, hip, and pelvic pain diagnoses.
Do You Experience One or More of the Symptoms Listed Below?
- Lower back pain
- The sensation of low extremity: pain, numbness, tingling, weakness
- Pelvis/buttock pain
- Hip/groin pain
- The feeling of leg instability (buckling, giving way)
- Disturbed sleep patterns due to pain
- Disturbed sitting patterns (unable to sit for long periods, sitting on one side)
- Pain going from sitting to standing
Making a Diagnosis
A variety of tests performed during the physical examination may help reveal the SI joint as the cause of your symptoms. Sometimes, X-rays, CT-scan, or MRI may be helpful in the diagnosis of SI joint-related problems because they can rule out other common sources of pain—such as your lumbar spine or hip joints. It is also important to remember that other conditions (like a disc problem) can co-exist with SI joint disorders.
The most relied-upon method to accurately determine whether the SI joint is the cause of your lower back pain symptoms is to inject the SI joint with a local anesthetic. This diagnostic injection will be performed under either X-ray or CT guidance to verify the accurate placement of the needle in the SI joint. If your symptoms decrease by at least 50%, it can be concluded that the SI joint is either the source of or a major contributor to your lower back, hip, or pelvic pain. If the level of pain does not change after SI joint injection, it is less likely that the SI joint is the cause of your pain.
Once the SI joint is confirmed as the cause of your symptoms, treatment can begin. Some patients respond well to physical therapy, the use of oral medications, or injection therapy. These treatments are often performed repetitively, and frequent symptom improvement using these therapies is temporary. If non-surgical treatment options have been tried and do not provide long-term relief, your surgeon may consider other options, including the minimally invasive iFuse procedure.