CERVICAL SPINAL PROCEDURES
Anterior Cervical Discectomy And Fusion
For patients who have cervical stenosis or cervical disc disease, an anterior cervical discectomy and fusion may be recommended. The procedure provides relief for people with neck, arm, and hand pain caused by arthritic bone spurs or herniated disc(s) pressing on one or more nerves. This procedure also provides relief for people suffering loss of function because of compression of the spinal cord from either bone spurs or herniated disc(s).
During the procedure, an incision is made in the side of the neck, often in a skin crease to minimize the visibility of a scar. Metal retractors are used to protect the trachea, esophagus, carotid artery and jugular vein, and the use of retractors may cause a sore throat for a short period following surgery.
The surgeon will use an operating microscope for better vision when removing the disc, bone spurs and protrusions, as well as enlarging the opening for the nerve roots. Typically, a synthetic interbody strut (mechanical characteristics essentially the same as bone) is used to replace the disc. This strut is packed with some of the patient’s own bone shavings as well as donor bone which has been sterilized and specially prepared to aid in the healing process. In the past, the patient’s own hipbone was used to replace the disc. While this was extremely successful, for far too many patients the resultant hip pain outweighed the benefits. Overall, the use of synthetic strut, local bone and the donor bone (as described) yields similar results, without the risk of pain at the hipbone. Occasionally, due to certain medical reasons, the patient is better served by the use of his/her own hipbone. The replacement bone is inserted between two vertebrae, and a secure fusion forms over the next few weeks to months, and continues to mature. This fusion will eventually provide lifelong natural support. A titanium plate and screws may be added to serve as a stabilizer until the fusion is complete.
Post-surgery, the surgeon may require the patient to wear a neck collar for several weeks. Depending on the extent of the surgery, patients are able to return to normal activities. As a rough estimate, expect four weeks for one level, 6-8 weeks for two levels, and 8-12 weeks for 3-4 levels. It is very important to remember that everyone heals at their own pace. As a result, we customize our care to fit each patient’s individual needs.
For most patients, the typical post-surgical hospital stay is 24-48 hours, however patients undergoing a one level discectomy may go home the same day. Any mild discomfort at the surgical site can be addressed through oral pain medications and the minor sore throat that often accompanies the procedure clears up quickly. Symptoms may improve immediately or gradually, dependent upon the patient’s preoperative condition, compliance with health care provider recommendations and realistic expectations following the surgery. Patients who smoke cigarettes should cease immediately because smoking significantly interferes with the bone’s ability to heal. Patients are encouraged to walk immediately after surgery, but bending, lifting and twisting are to be avoided for at least four to eight weeks.
Anterior Cervical Corpectomy and Fusion
When the area that requires decompression cannot be adequately addressed by anterior cervical discectomy alone, a corpectomy may be needed. This procedure typically involves the removal of two discs in the vertebral body between them in order to decompress the cervical spinal cord and spinal nerves. Occasionally, only part of a vertebral body is removed as necessary for decompression. The removed bone and discs will be replaced by a cylindrical synthetic interbody strut packed with some of the bone removed from the patient, as well as a specially prepared donor bone. In rare cases, due to certain medical conditions, use of a piece of the patient’s own bone (usually hipbone) will be recommended. An anterior plate and screws will be used to provide further stability while the bone heals and grows to provide lifelong natural support.
Atlantic Brain & Spine utilizes Intraoperative Monitoring of the Nerves (IOM) for surgeries that require manipulation of the spine. This technique allows the surgeon to monitor the nervous system in real time during a complex surgery. Electrodes are placed throughout the body, depending on type of surgery and the conditions, and the feedback allows the surgeon to detect problems as they arise, preventing permanent nerve damage.
For most patients, the typical post-surgical hospital stay is 24-48 hours. Any mild discomfort at the surgical site can be addressed through oral pain medications and the minor sore throat that often accompanies the procedure clears up quickly. Symptoms may improve immediately or gradually, dependent upon the patient’s preoperative condition, compliance with health care provider recommendations and realistic expectations following the surgery. Patients who smoke cigarettes should cease immediately because smoking significantly interferes with the bone’s ability to heal.
Cervical Disc Arthroplasty
Cervical disc arthroplasty is a newer procedure that attempts to provide decompression in the same manner that anterior cervical discectomy does while replacing the interbody fusion implants/grafts and the anterior plate with a synthetic joint in order to maintain motion. The theory is that by maintaining mobility at that joint, the surrounding joints will be less likely to deteriorate in the future (referred to as adjacent level disease). While there are promising avenues with the use of this technique, so far it has only been extensively studied in limited settings. It is however, an excellent option in a specific subgroup of patients. For these select few, it can be a very good alternative to the standard discectomy and fusion.
The video demonstrates one implant. There are other devices that have FDA approval and the device that is best for a patient may be slightly different than the one in the video. All of these devices have the same essential core characteristics.
Posterior Cervical Laminectomy / Foraminotomy / Microdiscectomy
Far more common in elderly patients, spinal stenosis is a condition caused by degenerative changes that can result in enlarged facet joints, bone spurs and thickening of the ligaments. Any of these factors can place pressure on nerves, causing pain, numbness and/or coordination issues. For relief, a cervical laminectomy may be indicated.
During a laminectomy, an incision is made in the back of the neck and the neck muscles are gently separated in the natural anatomic planes. The lamina is then removed, allowing the surgeon to see the nerve roots. A small portion of bone and/or disc material around the nerve root is also removed, creating space for the nerve root that is being compressed. The pressure and pain are alleviated, permitting healing to occur.
Patients typically spend one to two days in the hospital. Recovery and return to normal activity often depends greatly on the patient’s age and physical condition prior to surgery. Patients are encouraged to walk immediately after surgery, but bending, lifting and twisting are to be avoided for at least six weeks.
Posterior Cervical Decompression and Fusion
A posterior cervical decompression and fusion is a common surgical procedure to treat abnormal movement, pain and/or narrowing in the cervical spine (neck). Its goal is to relieve pressure on the spinal cord and nerve roots, or to help stabilize abnormal motion or neck instability.
LUMBAR & THORACIC
Lumbar Laminectomy / Foraminotomy / Microdiscectomy
Microdiscectomy is most commonly performed in the lumbar spine to relieve the pain that shoots down the leg. The pain is most often due to pressure on a nerve root resulting from a herniated (or bulging) disc. The surgeon will make an incision in the lower back about 1.5 inches long, gently part the soft tissues, place retractors to establish a surgical field and then use a high-speed drill and microscopic visualization to remove bone so that he can access the spinal canal. At that point, a small amount of ligament will also need to be removed so the nerve can be gently retracted, allowing access to the disc fragment and the disc space. The herniated, or out of position, disc will be removed in order to decompress the nerve root. The healthy part of the disc will be left in place to continue to do its job. The retractors are removed and the skin is closed. A first-time procedure that requires only one side to be exposed typically takes about one hour. A follow-up procedure may take 1.5 to 3 hours, depending on the amount of scar tissue present from the prior surgery.
Recovery varies from patient to patient. Many patients experience immediate and complete relief of leg pain; for others this is a more gradual process although a significant amount of leg pain relief can be expected. There will be incisional pain that can be readily managed by oral medications. Recovery from microdiscectomy has been significantly improved in recent years due to diminished soft tissue disruption with the traditional approach, as well as the avoidance of prolonged immobilization with the newer microendoscopic approaches.
It is important to begin to walk as soon as possible. This prevents a lot of the muscle aches and soreness that develop with inactivity. As important as beginning to walk is posture while walking, standing, and/or sitting. Gently increasing activity in the early course generally leads to a more rapid and less painful recovery. As expected, the recovery for a redo procedure can be more protracted.
Direct Decompression with Coflex Interlaminar Stabilization
The coflex device is a motion-preserving titanium implant that goes in the back of your spine to treat moderate to severe spinal stenosis. After the surgeon performs a direct decompression that removes bone, facet, ligament and/or disc segments from the narrowed spinal canal, your spine can become unstable. The coflex device is then inserted directly following a decompression procedure to help keep your spine stable while maintaining normal height and motion in your spine.
What is done:
- After a microsurgical direct decompression, the motion-preserving implant is implanted through a minimal incision and is placed on the lamina (the strongest posterior bone in the spine) to keep your spine stable
- This placement off-loads facet joints, maintaining the height between your bones for nerves to exit freely
- Both leg pain and back pain are relieved long-term*
- Motion is maintained in both the treated area as well as the area above the device
- Less time in the operating room, less blood loss, and less days in the hospital*
- Faster relief of symptoms and quicker recovery (pain and function measurements)*
* Claims based on FDA PMA P110008, October 2012 and ESCADA data, published in Journal of Neurosurgery: Spine. Volume 28 Issue 4, April 2018.
As the name implies, spinal fusion involves fusing together two of more vertebrae. This surgical procedure uses bone grafts, as well as metal rods and screws.
Among the conditions that may be corrected with spinal fusion are: vertebrae injuries, slipped or herniated discs, abnormal curvatures of the spine (including kyphosis and scoliosis), and a weak or unstable spine resulting from tumors or infections.
By eliminating or reducing motion between vertebral segments, the procedure can significantly reduce pain in many patients. Spinal fusion may also stop the progression of spinal deformities, such as scoliosis. While some flexibility may be lost as a result of the fusion, most spinal fusions are performed on very small segments of the spine so limited movement is not usually an issue. The material most commonly used in spinal fusion is human bone—either taken from the patient (autogenous bone) or harvested from a donor (allograft bone). While autogenous bone may fuse together more readily, that choice involves additional surgery to remove bone from the patient’s hip. Allograft bone may easily be obtained from bone banks.
Following bone grafting, the vertebrae must be held immobile with metal rods and screws to allow fusion to occur. In some cases, external bracing and/or casting may also be necessary.
The videos listed will acquaint you with the various types of IBF (interbody fusion) approaches, including anterior, posterior, transforminal and axial. A lumbar interbody fusion may be performed through a minimally invasive surgery approach known as AxiaLIF (Trans1).
In all cases, the damaged disc is removed, releasing the pressure on the affected nerve(s) and relieving the pain. The space created by removing the disc is replaced with bone graft material, sometimes through the use of interbody cages or rods. The bone graph may be self-donated by the patient, or come from a bone donor.
The bone graft fusion provides the immobilization necessary and therefore replaces the metal rods and screws of traditional spinal fusion, as well as post-operative back braces.
Posterior Lumbar Interbody Fusion(PLIF) / Transforaminal Lumbar Interbody Fusion (TLIF)
POSTERIOR LUMBAR INTERBODY FUSION (PLIF)
Accomplished by surgical incision in the back, PLIF requires the surgeon to move the back muscles out of the way in order to gain access to the spine.
TRANSFORMINAL LUMBAR INTERBODY FUSION (TLIF)
With this technique, the surgeon goes through the back to access the disc space, but inserts the bone graft from the side.
Extreme and Oblique Lateral Approach to The Lumbar and Thoracic Spine
Also used to treat the pain of degenerative disc disease, the lateral approach is much less invasive than some traditional techniques because it avoids going through the back and disrupting major muscles. The procedure can often be done on an outpatient basis with two small incisions in the patient’s side. Part of the damaged disc is removed, and is replaced with a bone graft implant that eventually fuses into a solid bone bridge. The process also relieves the pressure on pinched nerves in the area.
Spinal Deformity Surgery
Treatment of spinal deformities is an area of special interest for Dr. Alsina. He is very experienced in caring for patients with conditions that cause the spine to misalign, as in Scoliosis and Kyphosis, and is especially passionate about this work.
SPINAL FUSION: This surgery corrects spondylolisthesis, in which fractured bones or weakened joints allow a disc to slip forward and pinch a nerve root. This often causes pain to radiate to the legs and feet through the sciatic nerve. Any bone that is pressing on a nerve is removed, and bone grafts are added to the side of the spine. The grafts are held in place with rods and screws. The grafts will eventually fuse into solid bone and keep the discs from further slippage.
LUMBAR CORPECTOMY: To correct spinal curvature, a surgeon may perform a lumbar corpectomy. The procedure is done through the patient’s side, removing diseased or damaged discs and relieving pressure on the spinal cord. The surgeon will open up the vertebrae space, which reduces the deformity and allows for a straighter spinal alignment. A bone graft is inserted into the space vacated by the disc, and the surgeon uses a metal bridge, as well as metal bolts and screws to secure the graft and anchoring vertebrae in place. The graft fuses over time.
Dorsal Column Stimulation / Spinal Cord Stimulation
For treating chronic or severe pain that originates in the nervous system and does not respond to other treatment options, physicians may opt for an implantable medical device known as a Spinal Cord Stimulator (SCS) or Dorsal Column Stimulator (DCS). The device works through an electrical impulse that replaces the patient’s perception of pain with a tingling sensation.
A surgical procedure places small electrical wires on the spinal cord, and a pulse generator is implanted in the side of the back, upper hip area, abdomen or buttocks. Most often, the procedure is done under local anesthesia with the patient mildly sedated.
Following the implantation, patients often find the pain is completely gone or greatly reduced, and is replaced by a constant sensation of stimulation. Because it is difficult to predict which patients will be helped by the procedure, temporary wires are first used.
Kyphoplasty is a surgical procedure in which a doctor uses an inflated balloon to return a fractured vertebra to its original position. This process can alleviate pain, stabilize the bone and even restore lost body height resulting from compression fracture. Individuals with osteoporosis make up most kyphoplasty patients, but not all people with that condition will be good candidates.
The surgeon places a narrow tube into the back via a small incision. Fluoroscopy and x-rays assist the surgeon in locating the fractured area. Once the balloon is inserted through the tube, it is carefully inflated, which elevates the fractured area and compacts soft inner bone. A cavity is created inside the vertebrae, which is then filled with a cement-like material after the balloon is removed. The material hardens quickly, which stabilizes the bone.
Kyphoplasty surgery is often used to treat a fracture from osteoporosis. The surgery is usually performed at a hospital under local or general anesthesia, and it takes about one hour per vertebra. Most often, patients will spend a day in the hospital following this procedure.
Relief from pain will often be immediate, or will subside or disappear within a couple of days. Patients may usually resume normal daily activities, but should avoid strenuous exertion for six or more weeks.
A minimally invasive procedure, vertebroplasty utilizes acrylic bone cement to fill in the spaces of a fractured vertebra. This process seeks to stabilize the spinal fracture, thereby eliminating the associated pain.
Vertebroplasty can usually be accomplished in about one hour, with local anesthesia and light sedation. Because the procedure involves a small puncture instead of an open incision, the patient will usually be released the same day.
Once inserted via a very small needle, the acrylic bone cement hardens within 10 minutes, leaving a congealed, stabilized bone—a sort of internal cast for the vertebra.
While patients are generally alert and mobile following the procedure, they should not drive themselves home or ride long distances immediately after the procedure. Additionally, patients who are frail or will not have assistance at home may need a short hospital stay.
Bed rest for 24 hours after the surgery is usually recommended, and the patient can gradually resume activities thereafter. Minor soreness is usually relieved with an ice pack.
Outcomes are often very favorable with vertebroplasty, with the majority of patients experiencing a 90 percent or better reduction in pain as quickly as 24-48 hours following surgery.
Intrathecal (Spinal) Pump Placement
For patients with chronic pain who have not had satisfactory results through conservative treatments and are not likely to be relieved through surgery, an Intrathecal Pump Implant can make life much more pleasant. A temporary system is implanted first, and if the pain is reduced, a permanent system may be implanted. The pump/catheter system delivers a small amount of medicine to the designated area of the spine, preventing pain signals from being perceived by the brain. Regular doctor visits are needed to refill the pump, which usually lasts 3-5 years before needing to be replaced.
Craniotomy for Tumor
A craniotomy is a type of brain surgery that includes opening the skull, most often to remove a brain tumor. The patient’s head is shaved for the procedure, and the surgeon cuts out a piece of bone from the skull in order to gain access to the brain. Once all or part of the tumor has been removed, the opening in the skull is covered, typically with the same piece of bone. Wire mesh or screw plates may be used to hold the bone in place, and the skin is closed with either stitches or staples.
If blood or fluid remain in the brain tissue, the surgeon may place a drain through one of the surgical openings. Typically, the drain is only in place for a few days.
Hypophysectomy, or hypophysis, is the surgical removal of the pituitary gland.
A pea-sized endocrine gland in the center of the brain, the pituitary produces hormones that regulate the body’s growth and metabolism. The pituitary is an important gland, so steps are taken to preserve it whenever possible, or at least partially preserve it. However, for cancers and other tumors that resist less drastic forms of treatment, hypohysectomy may be necessary. Additionally, the procedure is sometime used to treat Cushing’s Syndrome, a hormone disorder that often leads to benign tumors called pituitary adenomas.
Because the pituitary is located directly behind the nose, surgeons often access it through the nose or sinuses. For some cases, a craniotomy (opening of the skull) may be necessary.
New medical technology is making other surgical approaches possible. Stereotaxis uses x-rays or scans for guidance, allowing instruments access to the brain through tiny holes in the skull. This method is highly accurate, and allows surgeons to manipulate (destroy or remove) brain tissue. It is also used to deliver radiation to the brain with extraordinary precision.
In cases where other therapies for Chiari malformation (CM) are not successful and the patient has either unbearable pain or consistent nervous system issues, surgical decompression may be needed.
An incision at the back of the neck allows the surgeon access to the base of the skull and the upper vertebrae. A bone and two vertebrae are removed, the spinal cord covering is cut and a patch is sewn in that allows for the free flow of spinal fluid. The procedure releases pressure on the spinal cord caused by the Chiari malformation, which provides relief to the patient.
Microvascular Decompression for Trigeminal Neuralgia
This procedure is done to eliminate or greatly reduce the pain caused by a blood vessel (usually an artery) pressing on the trigeminal nerve in the face. A small opening is made in the skull, and the surgeon negotiates around the dura (protective covering of the brain) and the cerebellum to find the problem artery. He then pushes the artery away from the nerve, relieving pressure and pain, and inserts a sterile pad to protect the nerve from further contact with the vessel.
Ventriculoperitoneal (CSF) Shunt
Hydrocephalus is the condition of having an abnormal accumulation of ceberbrospinal fluid (CSF) in the cavities of the brain. The condition may cause excess pressure inside the skull, which can result in the gradual enlargement of the head (in small children), headaches, decreased consciousness, and in extreme cases, death.
CSF shunts are the most effective way to remove the excess CSF and therefore, pressure. The fluid is drained from the ventricles, or cavities, into another absorption site (such as the right atrium of the heart or the peritoneal cavity) through a series of catheters. A valve, which functions as a regulatory device for the fluid, may be used along the catheter pathway.
Craniotomy for Arteriovenous Malformation
An arteriovenous malformation (AVM) is an abnormal tangle of blood vessels in the brain or spine. Some AVMs have no specific symptoms and little or no risk to one’s life or health, while others cause severe and devastating effects when they bleed. Treatment options range from conservative watching to aggressive surgery, depending on the type, symptoms, and location of the AVM.
This reconstructive surgical procedure is performed to correct congenital problems of the skull, or to repair the skull after a traumatic injury or medical procedure. During the procedure, a custom plate made from porous plastic or titanium is fitted over the defect in the skull, restoring the skull to its normal shape.
Ulnar Nerve Transposition
This outpatient procedure, performed under general or regional anesthesia, repositions the ulnar nerve to prevent it from sliding against or becoming pinched by the medial epicondyle (the bony bump on the inner side of the elbow). Ulnar nerve transposition is used to treat cubital tunnel syndrome.