5 Benefits of Minimally Invasive Spinal Fusion Surgery

1. Lateral Lumbar Interbody Fusion (LLIF), a minimally invasive technique for spinal fusion, does not damage or separate the muscles of the low back. This allows an easier time retraining weakened back muscles with physical therapy, as those suffering from chronic back conditions also have weak or atrophied muscles on top of their spinal condition.

2. Minimally invasive spinal fusion requires neither the cutting of bone nor the movement of blood vessels, which is required in traditional varieties of spinal fusion.

3. The LLIF method can be used to treat a wide range of conditions, including spondylolisthesis, nerve impingement, some tumors, herniations, as well as a host of issues caused by degenerative disc disease and degenerative scoliosis.

4. Patients undergoing LLIF and most other minimally invasive spine surgeries usually do not require an overnight hospital stay.

5. Patients treated with minimally invasive spinal fusion are up and about within a few hours of surgery and report minimal pain and a quick recovery.

Is Minimally Invasive Spine Surgery Performed on the Neck?

Yes, minimally invasive spine surgery is an option for those with damage to the cervical spine (neck), as well as to those with injuries lower in the back. Patients with chronic neck pain who are not helped by conservative treatment may benefit from surgical treatment. Patients should consider surgery if they fail to improve with conservative therapy, have severe pain, weakness, cervical myelopathy, spinal cord dysfunction, spinal cord compression, and spinal cord swelling on an MRI scan. A discectomy is done to remove the disc compressing the nerves and spinal cord. The disc can be removed from through the front or back of the neck.

Most discs are removed through the front of the neck.  After the disc is removed a bone plug is inserted into the cleaned out disc space to hold the vertebrae apart. The vertebrae are then secured together with metal plates and screws.  Over time the two vertebrae and bone plug will fuse together.

New cervical neck endoscopes are being designed to remove the disc herniation without fusion and instrumentation. An endoscope is a micro video camera the size of a pencil which can be inserted through an incision the size of a fingernail. The camera then projects the images onto a video screen so the surgeon can easily visualize the disc compression.  Tiny instruments are inserted through the camera to decompress the nerve, which quickly provides relief from pain and suffering.

Cervical discs can be removed through the back of the neck.  The lamina in the rear of the spine is found and partially removed, exposing the disc that is pinching the nerve. The disc is then carefully removed.

New minimally invasive techniques allow this surgery to be done through a small tube inserted between the neck muscles, which decreases the muscle damage and weakness caused by muscle retraction. The disc and pinched nerve are found with the microscope and decompressed. The patient usually recovers quickly and without complication.

What is Spinal Stenosis?

Spinal stenosis is narrowing of the spinal canal.  This may be inherited, that is you were born with a small canal, or acquired, the spinal canal became smaller over time from degeneration, that is bulging discs, bone spurs and thickened ligaments.

As people age, the neck begins to “wear out”.  This begins with the drying out and collapse of the cervical discs.  This collapsed disc changes the forces across the spine and results in abnormal motion.  To stop this motion the body strengthens the neck by thickening the spinal ligaments and stabilizing the mobile joints with bone spurs.  This is especially seen behind the vertebral bodies, around the facet joints located at the side of the spine and in the ligamentum flavum (yellow ligament) at the back of the spinal canal.   These changes lead to decrease in the size of the spinal canal and may result in spinal cord compression.

Spinal stenosis may cause spinal cord injury and dysfunction called myelopathy. This may be due to compression, abnormal spinal motion or poor blood supply.   Myelopathy commonly presents in older people with neck pain, clumsy hands and difficulty walking.   This may be associated with pain, numbness, tingling, weakness, coordination problems (doing up buttons, fastening bra and eating), arm and leg stiffness, and bladder and bowel dysfunction.   People must rush to the bathroom to prevent incontinence.   Head movements may cause electrical shocks to shoot down their spine.   At times people may show slow decline in mobility:  from a cane to walker to wheelchair.  Very rarely, spinal stenosis can cause paralysis.

Endoscopic Treatment of Herniated Discs

Unfortunately, the spine suffers wear and tear as people age. This process is known as degeneration. Degeneration is usually first seen in the discs of adults in their thirties to fifties.  The annulus, the thick fibrous cartilage that surrounds the interior of the disc, may weaken. This allowing the nucleus that makes up the interior of the disc to overflow, which forms a bulging disc.  If the annulus tears, the nucleus may squeeze out forming a herniated disc. The disc may compress or “pinch” spinal nerves, causing the back and leg pain, numbness, tingling and weakness known as sciatica. This pain may be worsened or maintained by inflammation around the nerve roots in the spine.

Possible risk factors for ruptured discs are injury, smoking, pregnancy, jobs involving heavy lifting, repetitive lifting and twisting, or operation of heavy vehicles.

Patients who are not helped by more conservative treatment may benefit from surgery. Traditional surgery is destructive to the spine.  The larger the incision the more damage to skin, muscle, ligaments and bone. This collateral tissue damage may result in more pain, muscle weakness, spinal instability and scar tissue which could lead to future difficulties.

Minimally invasive surgery involves a skin incision of less than one inch, but it is more than just a small incision. The surgery is done through a tube that slides in between back muscles to decrease the muscle damage and weakness caused by muscle retraction.  As noted earlier, this is not the same as “microsurgery”, which only refers to surgery that involves the use of a microscope, not the size of the incision or the amount of muscle damage.

Endoscopic spine surgery is state-of–the-art minimally invasive spine surgery. During an endoscopic discectomy, a micro video camera is inserted through a very small incision to locate the disc that is pinching the nerve.  The camera projects the images onto a video screen so the surgeon can easily visualize the compression. Tiny instruments are inserted through the camera to decompress the nerve, relieving pain and suffering.  The advantages of this type of surgery include no general anesthesia, a very small incision, minimal post-operative pain, and a shorter recovery then traditional surgery.

The endoscopic discectomy is an excellent choice for someone suffering from recurrent disc herniation after traditional discectomy because it avoids most of the old scar tissue. This decreases the chance of spinal dural tears and spinal fluid leaks. Traditional discectomy is done through a midline incision.  A second surgery must deal with the scar tissue from the first operation, increasing risk of complications.  Endoscopic surgery is done from the side of the spine instead of the rear, avoiding most scar tissue and potential problems.

If you have been suffering from chronic back pain due to bulging or herniated discs, an endoscopic discectomy might help. Find out if you are a candidate for minimally invasive treatment by making an appointment today.

Can Pilates Help My Back Pain?

Many patients experience relief from their back pain through physical therapy, but I have had patients ask me if they could substitute Pilates for physical therapy. While I always recommend speaking to your doctor and physical therapist before trying a new exercise routine, Pilates does seem to help many patients strengthen an ailing back and gain flexibility.

What is now known as Pilates was developed by Joseph Pilates during World War I. He rigged springs to hospital beds, which allowed bed-bound patients to exercise. This form of rehabilitation has been taken up by many athletes and dancers, and is particularly popular in the dance community.

If you have a back injury or have recently had back surgery, it is important to practice Pilates under the supervision of a qualified instructor, after the activity has been approved by your doctor or surgeon. It is often best for those suffering from chronic back ailments to take a few one-on-one classes with a certified Pilates instructor to better understand the form of the exercises, as well as the patient’s own limitations. After this introductory period, the patient might be able to move on to either online or in-person mat classes. Some exercises may be too challenging or damaging to those with specific back problems, so it is best to learn what movements to avoid before practicing alone or in a large class.

Pilates can be greatly beneficial to those suffering from back pain, as it strengthens the postural muscles and promotes the awareness of neutral spine alignment. It also increases the strength and flexibility of the shoulder and pelvic girdles, improving overall posture. Many Pilates exercises are full body movements which engage both the back and core. Strengthening these muscles can be very helpful to those with chronic back pain, as it can decrease gradual wear and tear by improving posture, as well as by strengthening the crucial supportive muscles of the back. If there is degeneration between vertebrae, strengthening the surrounding muscle can help support the ailing spine.

Back patients should make sure to avoid movements that include either extreme flexion or extension of the spine, as well as side bending with flexion or twisting. Your physician or physical therapist should be able to help you determine which movements should be restricted so that you can enjoy the benefits of Pilates without injury.

Relief of Annular Tears with Endoscopic Discectomy


The spine is made up of many bones called vertebrae. These vertebrae surround and protect the spinal nerves and lower part of the spinal cord from damage. Discs are located in between the spinal vertebrae and are made up of a tough outer shell called the annulus fibrosis and a soft spongy gel-like center called the nucleus pulposus. You can think of the disc like a jelly donut. The annulus is formed by many layers like “tape” stuck together.  The discs are named in reference to the spinal vertebrae. The disc between L4 and L5 vertebrae is called the L4-5 disc.  Similarly, the disc between L5 and S1 vertebrae is called the L5-S1 disc.


If too much stress is placed on the disc, the annulus – the outer shell – may rip, forming an annular tear.  There are three types of annular tears:


1.     Radial tears – A radial tear is a tear that goes all the way through the annulus, forming a channel connecting the inside to the outside of the disc.   The nucleus pulposus – the gel-like center of the disc – may extend into the tear and prevent it from healing. Radial tears are the most important annular tears because they often cause back pain. Back pain caused by injured discs is called discogenic back pain.  Radial tears may also cause leg pain by leaking inflammatory chemicals (such as tumor necrosis factor) from the nucleus pulposus onto spinal nerves.  This causes irritation and inflammation, resulting in pain.


2.     Concentric or circumferential tears – The wearing out of the annulus may lead to separation of the annular fiber layers like the layers of an onion, leading to weakening of the annulus. This results in a bulging of the disc.  Concentric tears do not usually cause back pain.


3.     Transverse tears – The tearing of the annulus’ connection to the vertebral body. These do not usually cause back pain.




Annular tears may be diagnosed on a work up for back and leg pain. They are seen as a white spot on MRI called a High Intensity Zone.  Discogram and CT scans best demonstrate annular tears and may indicate if it is the cause of a patient’s back pain.  Discogram is an interventional pain procedure done under X-ray guidance to determine which disc is causing pain.


Annular tears that are not successfully resolved with conservative treatment may be treated surgically. The treatment of annular tears must be individualized.  Unfortunately not every patient will be a candidate for surgical treatment.


Traditional surgery involves a large incision, muscle retraction and bone removal to expose the spine for disc removal and fusion.  This may be done through the abdomen [anterior lumbar interbody fusion(ALIF)], side [direct lateral interbody fusion (DLIF)] or back [posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF)]. The spine is then held together with pedicle screws or clamps.  Today there are many minimally invasive options, from injections to endoscopic disc surgery and minimally invasive fusions.  The most promising new procedure appears to be endoscopic discectomy.


The endoscopic discectomy treats pain resulting from a torn disc by removing the painful disc with the annular tear.  This disc is found and removed through the endoscope, which provides rapid pain relief and a shorter recovery time than traditional back surgeries.


6 Signs of Herniated Disk or Slipped Disk


  1. Leg pain – this may be pain radiating down the back or the side of the leg to the knee or foot.   Sometimes this pain is felt in the front or inner thigh or even the groin.  The pain may worsen with straightening the leg or siting up.   Arthritis pain is different from slipped disk.  arthritis pain  is usually only found in the hip, knees or ankle and does not radiate down the whole leg.
  2. Numbness and tingling – this may be felt as pins and needles, burning or decreased or absent feeling in the area of the pain or beyond it.  Sometimes numbness may appear without pain.
  3. Weakness – the leg may give out or drag.  You may have problems getting up from sitting, stepping onto a stool or moving your foot.
  4. Reflex loss – patients may loose reflexes at their knee or ankle or from the bottom of their foot.  Usually this is picked up from your doctor.
  5. Walking – the leg may drag or catch on the floor, you may have to lift the leg high to avoid this
  6. Bowel and bladder – if the disk compresses the cauda equina (the nerves to the bowel and bladder)  the bowel and bladder may stop working.  You may retention of pee or bowel movements or become incontinent of them.  If this happens you should seek medical attention immediately.

About Dr. Carl Spivak

Dr. Spivak is the president of Executive Spine Surgery and has offices in New York and New Jersey.  He is well known for his cutting-edge, minimally invasive endoscopic spine surgeries and regularly teaches courses throughout the USA.  For more information please call 908-452-5612 or click on schedule-an-appointment.

6 Best Treatments for Back Pain

1. Physical therapy focusing on core strength and flexibility.

2. Weight loss.  Weight loss alleviates back pain by reducing stress and strain on your back and decreases damage to disks and joints.

3. Steroid injections may relieve back pain.  Steroids and local anesthetics work to decrease inflammation, washout chemicals that cause pain and directly reduce pain often breaking the destructive pain cycle.  Steroid injections are an effective treatment for conditions that cause back pain such as arthritis of the spine (called facet arthropathy) and disk disease.

4. Stem Cell Therapy.  Disk regeneration is a new therapy where stem cells taken from your hip are injected  into your damaged disk to regenerate the disk.  The stem cells make new disk cells increasing the fluid and size of the disk reducing back pain and suffering.

5. Endoscopic Laser Discectomy.  As the disk wears out, or degenerates, it turns black on MRI, collapses, bulges and may tear causing back pain.  Removal of the degenerated disk and treatment of the annular tear has been found to reduce back pain and suffering.   The discectomy and annuloplasty can be done with the spinal endoscope.  A scope the size of a pencil can be placed through an incision the size of your finger nail.  The disk is found and repaired under direct visualization.

6. Endoscopic Fusion. Painful degenerated disks, spinal instability, spondylolithesis may lead to severe back and/or leg pain.  This pain can be disabling.  Patients that have failed other treatments may be a candidate for fusion surgery.  Today fusion surgery can be done through a very small incision with the aid of an spinal endoscopic to reduce soft tissue and bone damage and quicken recovery.


Dr. Spivak is the President of Executive Spine Surgery and is a leader in Endoscopic Laser Spine Surgery.  He see patients in New York and New Jersey and teaches doctors his advanced surgical techniques throughout the United States.  For more information please call 908-452-5612 or click schedule-an-appointment.

Can spinal epidural steroid injection hurt my brain?

Spinal epidural injections are very common treatments for back pain and sciatica.  Sciatica is leg pain running down the back of your leg caused by a slipped disk pinching a nerve.  Imagine the disk is a marshmallow (even though it really isn’t).  The disk like a marshmallow may expand out if you squeeze it.


You can try this at home – take a marshmallow and squeeze it from the top and bottom.  See how the marshmallow expands out as you flatten it.  This is similar to a herniated disk .  The bulging disk may pinch a nerve causing the nerve to swell up and get “hot” called inflammation causing back and leg pain.

Spinal epidural steroid injections are the placement of steroid medicine into the spine onto the hot and swollen nerve to cool down the inflammation and relieve the pain and suffering.  Think of it like putting an aspirin on the nerve.

Even though spinal injections are generally safe there are risks and side effects to all medical procedures. These include bleeding, infection, dural puncture or “wet tap” causing headaches and nerve damage.  Patients may also experience increased pain, headaches, red face, anxiety, problems sleeping, fever, high blood sugar, decreased immunity, stomach ulcers, severe arthritis, cataracts and menstrual irregularities.

TO ANSWER YOUR QUESTION the most common way spinal epidural steroid injections affect your brain is through headaches.  Usually these headaches will resolve with time.  If they are related to “wet tap” you may require bed rest, caffeine, fluids and rarely blood patch.  Blood patch is the injection of blood into the spine to stop spinal fluid leak and “plug” the hole from the “wet tap”.


Dr. Spivak is a neurosurgeon fellowship trained in minimally invasive spine surgery and spinal epidural steroid injections.  He has practices in New York and New Jersey.  For more information on spinal epidural injections or laser endoscopic spine surgery please call Executive Spine Surgery at 908-452-5612 or click schedule-an-appointment.

How can I get relief from my bad back pain?

Sorry to hear about your back and sciatica. The L5-S1 disk is probably pinching your sciatic nerve causing leg pain called sciatica. Lumbar disk surgery may be considered if steroid injections have not relieved the pain. Traditionally lumbar disk surgery was done through a large incision with significant muscle retraction, damage and bone removal to get to the disk. Today most lumbar disk herniations can be removed minimally invasively with the spine endoscope. This outpatient surgery is done with a small camera the size of a pen through an incision the size of your finger nail. Most people have quick relief from their pain and decreased recovery.

Patients are admitted to the hospital or surgery center for same day surgery.  They change into a gown and IV and EKG stickers are placed by the nurse and taken to the preoperative area.  The patient is seen by the surgeon, anesthesia and nursing.  The risks and benefits of surgery are explained to the patient if not already done.  The patient then signs an informed consent sheet verifying they understand the risks and benefits of surgery and want to go ahead with surgery. The patient is then taken into the operating room.  The patient is sedated (called conscious sedation) or put to sleep (general anesthesia) by the anesthesiologist and then position face down onto the operating room bed. The back is cleaned with a disinfectant and then a drape is placed over the patient.  X-ray machine and endoscopic equipment are brought to the bed.  After the surgery is completed the patient is transferred back onto their bed and taken to the recovery room.

For more information on minimally invasive spine surgery (MISS), endoscopic spine surgery or laser spine surgery please call Executive Spine Surgery at 908-452-5612 or click on schedule-an-appointment.

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