Least Invasive Surgery

Introduction

About 60-80% of adult population is expected to have suffered at least one episode of back pain in their life. This statistic is second only to the common cold. Over the last half century, with technological advances, our understanding of spinal disorders and treatment options have increased tremendously. In the industrialized countries, in any given year, 3-4% of adult population is temporarily disabled and 1% permanently disabled by back-related disorder. The mainstay of spinal treatment remains non-operative, and about 80% of the most common disorders such as a disc herniation and arthritis of the spine respond to these measures. Acute back pain which is usually associated with minor sprain tends to respond to some rest, pain medication, anti-inflammatory medications, physical therapy, and chiropractic treatments. A significant number of patients do not tolerate physical therapy well, and this is often due to the fact that the pain level has not been brought down adequately by other measures before embarking on physical therapy. In those cases of intractable back pain and/or leg pain, some form of therapeutic injections may help. As a surgeon, a physical therapy program is an integral part of my treatment approach. As a physician, my aim is to get my patients pain-free and functional as quickly as possible preferably without surgical intervention. Moreover, I would like my patients to maintain whatever pain relief and functionality they gained from my treatment, and patients usually achieve this if they perform regular exercise programs and observe back precautions as instructed by physical therapists. With this approach I try to help patients avoid surgery. We succeed in this most of the time, however, about 10-20% of these patients (and this figure varies between populations) will require some form of surgical intervention at some point.

I obtained my training in orthopedics and spine surgery in Norwich, England (part of the Royal National Orthopedic Hospital residency training program); Princess Margaret Orthopedic Hospital and Edinburgh Royal Infirmary, Edinburgh, Scotland; and Case Western Reserve University, Cleveland, OH. During this rather lengthy training program, I learned and participated in most procedures currently in use both here and in Europe. This extensive exposure to the approaches in the management of spinal conditions has helped me design what I consider a very rational approach to spine care. My patients usually undergo a comprehensive non-operative treatment before considering surgery. Once surgery becomes the most reasonable option, the least traumatic approach which achieves the goals of short operative time, minimal surgical blood loss, least post-operative pain, short hospital stay, short time to recuperate and early restoration of function is usually suggested to the patient. The following is the list of the procedures available for my patients at Russellville Hospital, Russellville, Alabama.

Decompression Procedures

• Open decompression: In the lumbar spine, this is usually reserved for patients with spinal stenosis caused by bony spur formation causing narrowing space available for neural elements. [Click picture for larger view.]

• Minimally invasive decompression: This constitutes a major part of the spinal procedures I perform. At this time this is mostly for thoracic or lumbar disc problem. Minimally invasive disc decompression in the cervical spine (neck), which may be performed as an outpatient, is also available.

Advantages

• Avoidance of spinal canal
• Operative time 30-45 minutes
• Minimal blood loss
• Can be performed at all of the spinal levels
• Minimal scar formation
• Minimal damage to spinal muscles
• No injury to the bone and joints
• Minimal rehab and early return to work

[Click each picture for larger view.]

Spinal Fusion Procedures

• Conventional Open Procedures: This is mostly performed for patients who have severe arthritis of the spine, requiring decompression as discussed above. [Click picture for larger view.]

• Minimally Invasive Procedures: If decompression can be successfully done through minimally invasive approach, then it is also in the patient's interest to perform the fusion and instrumentation with pedicle screws with minimally invasive approach. With this approach surgical time, surgical trauma, surgical blood loss, hospital stay and recovery time are significantly reduced. This is currently one of the most common techniques I use. Pictures below illustrate single- and seven-level decompression, fusion, and pedicle screw fixation of lumbar spine. [Click each picture for a larger view.]

Non-Fusion Procedures

• Dynamic Stabilization: One of the down sides of spine fusion is that by stiffening the diseased segment of the spine, stresses of the spinal motions are transferred to the neighboring joints, and this is thought to accelerate wear and tear of those neighboring segments. Recently a device called X-STOP was approved by the FDA for general use in the USA. It is a minimally invasive device which can help relieve back pain and leg pain without resorting to major removal of bone and fusion. This is now available at Russellville Hospital for selected cases. [Click each picture for larger view.]

• Total Disc Replacement: At this time, although one of the first to be trained in the implantation of Charitè Lumbar Disc prosthesis, I have not yet performed this procedure mainly because of the strict criteria I use for its application. For the appropriate candidate, the procedure is available. Recently the FDA has approved an artificial disc for the cervical spine (neck). This device is likely to be the most preferable procedure for my patients who have a single level disease of the cervical spine, currently treated with fusion. The approach for this operation is similar to fusion, which is widely performed in the USA, and the advantages include avoidance of neck brace, earlier return to normal activities and hopefully avoidance of stresses on the neighboring discs. [Click each picture for larger view.]