When a surgical treatment plan is composed, there are 3 fundamental elements which must be considered in every diagnosis and every ultimate strategy. Within any given spinal disorder, there are considerations involving decompression, reconstruction, and stabilization. Not all patients require all three implements to the different strategies. Sometimes in the presence of severe pain caused by a pinched nerve, a well conceived and targeted nerve decompression is all that is necessary. When accompanied by deformity or severe mechanical back pain, sometimes reconstruction becomes the important part of the treatment choice.
When considering a reconstruction, there are different methods of reconstruction. Reconstruction can be formed in a motion sparing manner or in a motion eliminating manner. For motion sparing procedures, newer technologies provide for flexible rods embraced by screws and/or artificial disc technology. For motion eliminating procedures or spinal fusion, rods and screws, intervertebral implants, better biologics including stem cell and bone morphogenic protein supplements all provide for increased rates of fusion while reducing the invasiveness of the procedure.
At NeuroSpine Institute, regardless of which of the treatment strategies is employed, all phases of each surgery fully encompass a minimally invasive treatment approach. In most cases, the approach and portal into the body is the same size whether it is a microsurgical decompression and/or reconstruction and/or stabilization. The investment within the portal or approach is the variable which is manipulated and increased. It is critically important that the strategy and long term goals be well understood prior to making those ultimate choices. Sometimes a person benefits from a minimalist approach with a decompression only, assuming that they have failed conservative treatment.
Sometimes in order to pursue a realistic life strategy based on their goals, needs, and life requirements, reconstruction is necessary. Again, the strategy being custom fitted to the particular circumstance, body type, conditioning level, psychological make-up, and ultimately life strategy.
Artificial Cervical Disc Surgery:
At NeuroSpine Institute, we are experts in artificial cervical disc, having performed as many artificial disc procedures as any practice in the United States. In many circumstances, a cervical disc becomes incompetent because of injury or wear and tear and historically treatment was designed to fuse the 2 vertebral bodies together across the broken disc. With advancements in artificial disc technology, most often the treatment of choice is motion preserving, maximizing rehabilitation, flexibility, and performance. An anterior cervical disc replacement surgery is performed exactly the same as an anterior cervical interbody fusion surgery, and the time tested results across the board are equivalent with regard to safety and efficacy.
The major advantage in artificial disc surgery over cervical fusion surgery is that the intermediate to long term performance, range of motion, and functionality is significantly improved with artificial disc surgery. There is also a theoretical advantage to artificial disc surgery in that it does not provide the same degree of stress at adjacent disc levels and theoretically does not have the same risk of needing yet another surgery at the disc above or below the treated disc failure level.
The recovery period for artificial cervical disc surgery is also considerably different from an anterior cervical fusion procedure. The typical artificial disc patient will begin passive range of motion postoperative day 1. We will initiate an aerobic and cardio exercise program to last the first several weeks with gradual passive and active range of motion based on severity of muscular pain and spasms. In many cases, the patient is able to return to full activity as early as 6-8 weeks. This compares with anterior cervical fusion surgery where 6-9 months is usually the required time for return to normal activity because it takes several months for the fusion to mature to the point of security and safety. In the athlete or highly skilled worker, this provides substantial advantage in that the individual is able to return to his activity at a higher level earlier with less time loss and with more conditioning than in the fusion patient, ultimately allowing for more functionality, less work loss, and better performance.
At NeuroSpine Institute, a microsurgical discectomy is performed with image guidance and microsurgical dissection through a 15mm hole to a highly defined target based on clinical symptomatology, history of illness, symptom progression and mapping, and ultimately the imaging correlates associated with the clinical syndrome. When a patient fails conservative therapy and undergoes a microsurgical decompression, the principal goal is to alleviate pressure on the symptomatic nerve root while minimizing potential harm to the spine and the treatment approach.
Our typical incision approach is 15mm or ½ inch. The time in surgery is between 30-45 minutes. Blood loss is minimal. Most often, this is an outpatient procedure. The patient can begin a walking program the first postoperative day, assuming clinical improvement is readily seen. In the first 2 months, care is taken to avoid twisting, turning, bending, and lifting out in front while maintaining excellent posture, gait, and stance and focusing on correction of any poor learned behavior or compensations.
A symmetrical vertical cardiac program and water therapy is ideal in recuperating and preparing for return to normal activity after 2-3 months. At NeuroSpine Institute, we have invented the methodology and surgical techniques for minimally invasive spinal reconstruction done by a single incision in the posterior midline lumbosacral spine. This technique characterized by the term IMAS (Interpedicular minimal access surgery) allows for all phases of the decompression, reconstruction, and stabilization to be done via a single incision in a posterior midline approach. This includes not only the decompression, the posterior segmental titanium hardware for stabilization, the intervertebral graft products for intervertebral body fusion and reconstruction, and further reduction of deformity or spondylolisthesis. The principals of IMAS allow for the least invasive surgical lumbar spine reconstruction methodology in the world, and prospective studies are currently under way to prove the efficacy, objectivity, and success of these new strategies.
Due to the improvements in methodology and technique associated with IMAS, many athletes and industrial laborers are able to return, without reservation, to previous activity despite a confirmed spinal fusion.
Unparalleled results are being seen in current patients compared with more traditional time tested reconstruction strategies performed over the last 20 years.
The fundamental goals of interpedicular minimal access surgery are accomplished by the use of high level intraoperative imaging and navigation, advanced microsurgical techniques and specific preoperative planning, allowing for precise targeting and decision making.
A patient who requires a lumbar reconstruction and stabilization via an IMAS technique frequently has an incision of roughly 15-20mm, blood loss in the order of 100-200cc, time in surgery of an hour to an hour and a half. Hospital stay is generally 1-2 days and progressive ambulation beginning the first postoperative day with a focus on gait, stance, posture, reversal of poor compensation techniques, gait patterns, and a gradual rehabilitation program with aerobic conditioning to maximize blood flow to the reconstructed area. Time away from strenuous activity and lifting range anywhere from 6-12 months, depending on the overall body habitus, level of conditioning, health, and youth of the patient.
Historically, a spinal revision surgery was amongst the most complicated and invasive surgeries available to the spine injured patient. With more modern techniques and planning, often the act of revising a previously failed spinal reconstruction surgery allows for the successful objectives to be maintained while focusing on very precise objectives within the original plan. In other words, it often is a fraction of the original surgery rather than starting from scratch and doing the entire surgery over again. Very often, the previous hardware can be removed via a single small, less than 1 inch, incision, assuming that the fusion is found to be intact and no further reconstruction is necessary.
At this point, a direct microsurgical targeting of entrapped nerve roots, particularly in the lateral recess or the foramen (the side gutter of the spine) can be directly accessed with meticulous navigation sparing the historically large wounds and significant blood loss and morbidity.
At NeuroSpine Institute, we are experts in the treatment of failed back syndrome and failed surgery syndrome and are frequently successful at finding the missing link to treatment success.
Obviously, this is an extremely complex problem and some people cannot be cured of their neurological injury, but our methodologies and techniques made us extremely successful at identifying the reversible problems and correcting them with minimal trauma and invasiveness.