Year: 2014

The Top Benefits of Endoscopic Spine Surgery

Due to the many advantages of endoscopic spine surgery, it should always at least be considered, but currently it is not a replacement for all types of spine surgeries. Fortunately, with the advancement of surgical techniques and equipment, it is being used to treat a wider scope of injuries.

Why might endoscopic surgery be an option when other types of spine surgery are not?
Traditional surgery is limited because the surgeon must see the problem directly, whether with their eyes or a microscope. The endoscopic camera visualizes areas that are not usually visually accessible through holes into the side of the spine and around corners. This greater visualization combined with minimal damage and lowered surgical risk increases the spectrum of pathology that can be treated safely. This allows endoscopic surgeons to treat spinal disorders that traditional surgery may not treat. This happened many years ago in orthopedic surgery, when the endoscope was introduced to knee surgery. Today no one doubts the incredible benefits of endoscopy of the knee, and we are quickly seeing this happen in spine surgery.

Can endoscopic spine surgery help everyone?
Sadly, not everyone can be helped by endoscopic spine surgery. It is still spine surgery, which has inherent risk that is off-putting to some patients. Other conditions simply cannot yet be treated by this technique. Endoscopic spine surgery is the next advance in the treatment of spinal disorders, but it is not a cure-all.

Why isn’t all spine surgery done this way?
These procedures require a unique combination of skills that take time to acquire. There are only a few surgeons who have focused on mastering these advanced techniques. Endoscopic spine surgery is a hybrid procedure that falls in between interventional pain and minimally invasive spine surgery. It is a relatively new, cutting-edge technique. Endoscopic spine surgery is the future.

What are the advantages to endoscopic spine surgery?
▪ No general anesthesia
▪ Very small incisions
▪ Minimal damage to skin, muscle, ligaments and bone
▪ Minimal blood loss
▪ Less post-operative pain
▪ Faster recovery

What is Facet Arthropathy & How is it Treated?

What is Facet Arthropathy?

The spine is made up of bones, discs and facet joints. The discs and facet joints allow the spine to flex, extend, turn and bend to the sides. The discs are located in the front of the spine; they support and allow movement between the vertebral bodies. The facet joints are located in the rear of the spine, one to two inches off the midline on the right and left sides. Facet joints are synovial joints lined with cartilage and filled with fluid. Each joint is held together by a thick capsule. These small joints allow the facet bones to slide back and forth with minimal resistance.

Unfortunately over time the facet joints break down from aging, wear and tear, injury, instability, and slippage of the spine. The gradual wear of the facet joints is called degeneration. These degenerative changes of the facet joints can produce severe debilitating pain.

Facet arthropathy is often called as arthritis of the facet joint. The most common cause of facet arthritis is osteoarthritis. Osteoarthritis causes breakdown and swelling in the cartilage of the facet joint, ultimately producing bone on bone rubbing or grinding. The body tries to stop this rubbing by thickening the joint, creating arthritis. This type of arthritis may produce pain and stiffness which worsens with the extension of the neck or back. If the joints enlarge too much, they can pinch nerves causing arm or leg pain or numbness.

Facet arthritis in the neck causes neck and shoulder pain, in the midback it causes midback pain and in the lower back it causes lower back, buttock, upper leg, and occasionally lower leg pain. Pain usually increases with extending (bending back) or twisting the neck or back, and the affected joints may be very tender to deep pressure on examination.

How is Facet Arthropathy Diagnosed?

Facet arthropathy may be diagnosed on X-rays, CT and MRI scans. CT scans may show thickened and irregular facet joints. MRI scans may show fluid in the joints (joint swelling), thickened ligaments and bones, as well as pinched nerves. These imaging studies only show the physical abnormality. They do not indicate if these changes are responsible for your pain.

To determine which structure is causing the pain, the patient may undergo pain mapping. Injections are used to locate where the pain is coming from. Numbing medicine is injected into the facet joint or onto the facet nerve (medial branch nerve). If the facet joint is the cause of the pain, the pain will stop or decrease. If the pain does not improve, then it is originating from other structures, such as the bones, discs, ligaments, spinal nerves, etc.

How is Facet Arthropathy Treated?

Patients who have not been helped by conservative treatment may benefit from surgical intervention. Traditionally these patients had been treated with either a large open fusion surgery of the discs and facet joints or facet joint injections and radiofrequency ablation. Radiofrequency ablation is an interventional pain procedure where electrodes are placed onto the facet joints to burn the nerves transmitting pain from the damaged facet joints. The burning electrodes are placed onto the spine under X-ray guidance. The nerves usually recover from the injury after six months or so and the pain returns. Fortunately radiofrequency ablation can be repeated.

Are There Minimally Invasive Treatments for Facet Arthropathy?

Facet joint pain can be treated with the spinal endoscope. Endoscopic rhizotomy treats pain that originates from the facet joints and medial branch nerves. A high definition endoscopic video camera the size of a pen is inserted through a tiny incision into the painful facet joints. The facet joints are cleaned of the painful tissue and the medial branch nerves are found and cut under direct visualization through the endoscope. This is like a “root canal” for the spine. Patients usually have almost immediate pain relief and quick recovery. Endoscopic rhizotomy may produce pain relief for years, unlike radiofrequency ablation which must be repeated every six months or so.

Severe facet pain that is not responsive to endoscopic rhizotomy may be treated by endoscopic fusion. Endoscopic rhizotomy blocks the majority of pain transmission from the joints, but not all. This prevents the patient from accidentally injuring himself. If the spine is unstable and puts extensive stress on the facet joints, or if there is significant pain originating from the disc or other structures, the spine may still need to be fused. Fortunately there has been much advancement in fusion technology and it can now be accomplished using minimally invasive surgery. This procedure is performed through a one inch incision with the help of endoscope or microscope.

Endoscopic fusion treats degenerative spinal disease and instability which can cause back and leg pain. The damaged disc is removed through the endoscope and spinal endplates are prepared for fusion under direct visualization. Endoscopic fusion is done under general anesthetic, facilitating the insertion of spinal instrumentation. Patients are usually discharged the same day after surgery, and have much less pain and a quicker recovery compared to traditional fusion surgery.

The Most Common Question About Minimally Invasive Spine Surgery

Why is endoscopic spine surgery better than traditional surgery?

Traditional surgery is more destructive in its approach to the spine, and often creates new damage while treating the problem. The larger the incision, the more damage to muscle, ligaments, and bone. This greatly increases the potential for muscle weakness. This collateral tissue damage may result in even more pain, weakness of the back muscles, spinal instability, and the buildup of scar tissue, all of which can lead to future difficulties. While the original problem might be repaired, new issues often arise, and sometimes the original issue can recur.

Within the realm of minimally invasive surgery, endoscopic spine surgery is extremely minimally invasive. The incision is very small, often less than one centimeter in size. There is minimal damage to the skin, muscle, ligaments and bone. Only local anesthesia is required, which greatly decreases medical risks and improves access to surgery for high-risk patients. There is very little blood loss. These benefits result in greatly reduced post-operative pain and a speedy recovery.

5 Frequently Asked Questions About Disc Herniation & Endoscopic Discectomy

1) Are herniated discs able to heal up over time?

Lumbar discs go through a process of degeneration. They undergo chemical changes that result in the drying out of the disc. During this process the discs collapse, turn black, start to bulge and form bone spurs in order to attempt to fuse the disc in place. Though the blood supply to discs are poor in adults and rarely heal up internally, disc herniations (protrusions, sequestrations and extrusions) may heal up on their own, especially when they are large. The body’s inflammatory system may break them down relieving pressure off the nerves (unpinching the nerves). The pain you experience may remain stable, improve or worsen over time. There is significant work being done in stem cell research (adult mesenchymal stem cells) for disc regeneration and the early results are encouraging, showing improved disc height and fluid level. There are other surgical procedures that are being investigated, such as making holes in the disc endplates with an endoscope to improve the blood supply to the disk. This has been shown to help heal degenerated discs. Over the next few years there will likely be many new treatments for degenerative disc disease.

2) Is a discectomy a permanent solution?

Discectomy does not remove the entire disc, only the part of that is causing problems. Most patients do very well with the surgery, particularly if it is performed endoscopically. There is 10% chance of the disc recurring or regrowing. There is also risk of the disc degenerating, leading to back pain and the spine falling apart (called slipped spine or spondylolithesis) which also could require further surgery. Spine degeneration is rarely limited to one disc and often people have multiple discs wearing out and any of them or a new one may become a problem in the future.

3) What is the recovery time for a discectomy?

Recovery time depends on the type of discectomy surgery you have, how long you have had the problem, and the presence (or lack) of nerve damage. Patients recover quicker from minimally invasive and endoscopic discectomies than traditional open surgeries. People who have had the problem longer or who have nerve damage usually take longer to recover. Most people recover from surgery in between 2 and 12 weeks.

4) Is a herniated disc the same as a disc protrusion?

Disc herniation and disc protrusion are generalized terms for describing a disc displaced or sticking out of the disc space into the spinal canal. Disc protrusion may be used more specifically to describe a disc displacement when the height is less than the width. Since the terms for describing disc herniations vary from doctor to doctor and there is little consistency to how they are named, the best way to determine if your disc has worsened is by having a radiologist or back surgeon directly compare your MRI films.

5) For disc problems, is there an alternative to spinal fusion?

Endoscopic discectomy “laser spine surgery” is an alternative to spinal fusion for degenerative disc disease. The disc is removed through a pencil sized endoscope via an incision the size of a finger nail. There is decreased tissue damage, pain, and recovery time compared to spinal fusion.

5 Common Questions About Sciatica & Minimally Invasive Spine Surgery

1) I have a pain in my left butt that goes all the way down my leg. What could that be?

Sciatica is back and leg pain resulting from pinching the sciatic nerve. This is most commonly caused by a slipped disk in the back. Today lumbar disc herniations may be removed minimally invasively with the spinal endoscope

2) I think I have sciatica. Should I see a GP or a Chiropractor?

I would recommend seeing your primary care doctor to orchestrate the workup and treatment of your pain. You will likely require anti-inflammatory medicine, physical therapy, an MRI scan and possibly steroid injections or surgery.

3) Will sciatica caused by a herniated disc get better without surgery?

Disc herniations rarely resolve on their own. It is more common for them to get a little smaller over time then resolve. Surgery is the best treatment to physically remove the damaged disc. Today this can be done endoscopically though a tiny incision.

4) What kinds of surgeries can help sciatica?

Sciatica is leg pain usually caused by a slipped disk in the spine pinching the sciatic nerve. The most common surgery for sciatica is discectomy, or removal of the piece of disk pinching the nerve. Today this can be done through a very small incision with an endoscope. Usually the pain resolves before you leave the operating room!

5) How successful is a discectomy at relieving back pain?

Discectomy best relieves sciatica leg pain. Back pain may be relieved after discectomy but it is not as consistent as leg pain. Patients with back pain without leg pain and degenerated herniated disk usually undergo a diagnostic test called a discogram to help determine if surgery will work.

Who Can Spine Surgery Help?

Pain in the lower back and legs can be caused by almost any structure in the back and many other organ systems. Patients with severe back and leg pains may have little abnormal findings on MRI scan and patients with no pain may have severe abnormalities, therefore it can be difficult to determine the exact causes of the pain. A good history and physical examination, radiological tests and nerve studies can identify most causes. The best outcome is when the person has typical symptoms (complaints), physical exam findings and MRI abnormalities. The less typical the complaints, the less likely the patient will benefit from surgery. If the exact cause cannot be identified or there are many possible causes, then pain mapping may be beneficial pinpoint the cause of the pain.

Pain mapping is the usage of spinal injections to delivery numbing or provocative solutions to suspected causes of the pain. Numbing medicine may block the pain and provocative medicine may worsen the pain.

The results of surgery are also affected by motivation, coping skills, psychological problems, drug addiction, lawsuits and worker’s compensation.

Failed Back Syndrome is when patients fail to improve or worsen after spine surgery. These patients often continue to take pain medicine and are unable to return to work. Failed back syndrome is not one specific problem but a generalized term for people who did not do well.

There are many causes for failed back syndrome including unrealistic expectations (they wanted to feel like they were twenty), incorrect diagnosis and treatment, correct diagnosis but wrong surgery or the problem was not properly fixed. There may be additional pain from a partially or unrecognized source. Bleeding, nerve damage or spinal leak may complicate surgery. A new problem may form after surgery, such as disc herniation, blood clot, infection or scar tissue. Muscle damage or bone removal may lead to spinal weakness, instability and new pain. The prospect of loss of income, personal attention or returning to a poor work situation may hamper recovery.

The potential for failed back syndrome can be limited if both doctor and patient are positive and have good communication and honesty. Thorough studies and an accurate diagnosis of the problem are essential as well. The attitude and expectations of the patient as well as his or her life situation must be considered by the treating physician as well for the optimum outcome.

What is Cervical Spinal Stenosis?

Spinal stenosis is the narrowing of the spinal canal, in this case the spinal canal in the neck, not the back (lumbar spinal stenosis).This may be inherited, that is you were born with a small spinal canal, or acquired, in which case the spinal canal became smaller over time from degeneration. This could include 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. In some patients, this is severe enough to be considered cervical disc degeneration. A collapsed disc in the cervical spine can change 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.

Cervical 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. 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. Rarely spinal stenosis causes paralysis.

Thankfully this condition can frequently be treated with minimally invasive spine surgery. Tools and a camera are inserted through a very tiny incision to remove bulging discs, bone spurs and impinging ligaments. If you are suffering from cervical spinal stenosis, make an appointment with a spine surgeon today to see if you are a candidate for life-changing minimally invasive spine surgery.

What is the MILD Procedure for Lumbar Spinal Stenosis?

MILD Stands for Minimally Invasive Lumbar Decompression. If your lumbar spinal stenosis is caused by excess spinal ligaments, then this quick out-patient procedure could be for you. Tiny instruments are inserted through an incision the size of a dime or smaller. These specialized tools allow your surgeon to remove the excess tissue that is causing your spinal canal to narrow, which reduces symptoms such as pain and tingling, and restores mobility. This relatively simple surgery does not require general anesthesia, and it does not even require stitches. Patients who have undergone the MILD procedure report increased standing time and a much greater ability to walk without pain or numbness. Like most minimally invasive surgeries, the MILD procedure has a very low risk of complications.

How do I know if the MILD procedure is for me?

If you are suffering from numbness, pain or tingling in your legs and/or buttocks when walking or pain or numbness in your lower back when standing, you may be suffering from lumbar spinal stenosis. You should should see a spine surgeon to evaluate the cause of your pain and see if the MILD procedure is an effective treatment for you.

What Do I Do For My Broken Back? Treating Osteoporosis Spine Fractures

As we age, a common problem, especially for women, is osteoporosis – the thinning and weakening of bones. One of the many problems caused by this dangerous condition is stress fractures of the spine, also known as wedge fractures, burst fractures, collapsed vertebrae, and broken back. As the body ages, the square vertebral body of the spine can weaken or be injured with excessive force. It may break and flatten like a pancake, causing back pain and misery. Osteoporosis is the major cause of vertebral body compression fractures; other less common causes include severe trauma, infection or cancer.

Pain is the most common complaint from spine fractures. Any movement causes micro-motion in the broken bone, which produces severe pain. This pain usually decreases when the patient lies down, and increases with standing, walking and lifting. Sometimes people have no pain at all. Rarely fractures may cause numbness, weakness, paralysis or bowel and bladder dysfunction from spinal cord or nerve compression. Fortunately, the severe back pain often improves during the first month after injury.

X-ray, CT, bone scan and MRI may diagnose spinal fractures. Besides diagnosing the fracture, MRI scans can determine if the fracture is new and rule out nerve or spinal cord compression.

Is there a surgical treatment for spine fractures?

Patients who do not respond to conservative treatment may benefit from surgical treatment. The key to surgical treatment is stabilizing the fracture. The spine, like a broken arm, must be “cast” to stop abnormal bone movement and prevent pain. Surgical options include vertebroplasty, kyphoplasty and major spine surgery. Major spine surgery is not commonly needed to treat osteoporotic compression fractures.

Vertebroplasty and kyphoplasty are the most common treatment for osteoporotic compression fractures. These procedures involve the placement of a needle into the fractured vertebral body for the injection of liquid cement. Once the liquid cement hardens it stabilizes the vertebral body decreasing painful movements. If there is concern for cancer then a bone biopsy is sent to pathology for examination.

Vertebroplasty is an outpatient procedure, done under conscious sedation like a colonoscopy, but can be done under local anesthesia in high-risk patients or rarely general anesthesia. A needle is placed into the fractured vertebral body under x-ray guidance and then liquid plastic is slowly injected to harden and stabilize the fracture.

Kyphoplasty is similar to vertebroplasty, but kyphoplasty involves the placement of two needles on each side of the spine and balloons into the broken vertebra under x-ray. The balloons are slowly inflated to expand the collapsed “pancake” vertebral body and create cavities to hold the plastic. Plastic is then injected after the balloons are removed to support and stabilize the broken vertebrae.

Women who developed vertebral body compression fractures are at least four times higher risk of developing future spine fractures. Elderly patients with bone fractures should undergo investigation and treatment for osteoporosis.

What is Lumbar Spinal Stenosis?

Spinal stenosis is the narrowing of the spinal canal. As people age, the lumbar discs dry out and collapse. In response, the body stiffens the spine by thickening the spinal ligaments and hardening the disc and facet joints with bone spurs. Unfortunately, these changes result in the narrowing of the spinal canal and the compression of the spinal cord, nerves and blood vessels. This decreases the blood supply and oxygen to the nerves, which produces leg pain. The brain thinks the legs are the cause of the pain when it is actually the pressure in the back.

Spinal stenosis usually develops in patients between fifty and eighty years old. It is characterized by slowly worsening back and leg pain, numbness, tingling and weakness. The pain may be constant, but is usually brought on by walking (called neurogenic claudication) or certain positions. It is relieved by sitting, lying down or using a shopping cart. People sometimes feel like they are walking on a cloud or cotton wool or that their legs do not belong to them. On rare occasions, patients may develop urinary and bowel incontinence or retention. If this happens they should immediately contact their doctor and go to the emergency room.

An MRI scan is the best test to see if spinal stenosis is compressing the nerves. A CT scan or CT myelogram (contrast dye injected into the spinal canal) is usually reserved for patients who cannot have an MRI. EMG (electromyelography) nerve studies can help confirm nerve irritation and injury.

Are there surgical treatments for lumbar spinal stenosis?

Patients who have not responded to conservative treatment may benefit from surgical treatment. Traditionally a large skin incision was made over the spine, and the back muscles were retracted to expose the spine in order to remove the lamina bones and ligaments compressing the spinal nerves. This is called a laminectomy.

Traditional surgery is more destructive in the approach to the spine compared to new minimally invasive surgery. 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 may lead to future difficulties. Many surgeons recommend the addition of a bone fusion and instrumentation with screws and rods with a laminectomy, due to the increased chance of the spine falling apart in the future due to damage from the surgery.

Minimally invasive surgery is done through a skin incision less than 1-inch, but it is more than just a small incision. The surgery is done through a tube in between back muscles to decrease muscle damage and weakness caused by muscle retraction.

New “extremely” minimally invasive endoscopic spinal surgeries are being developed for the treatment of spinal stenosis. The advantages of these procedures will include twilight sedation, very small incision (size of finger nail), minimal postoperative pain and shorter recovery then current minimal invasive or traditional spine surgery.