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SPINE SURGERY: WHERE WE ARE TODAY
SINA RAJAMAND, D.O.
NEUROSURGEON
ADVANCED NEUROSURGERY
RENO, NV
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WHEN DO WE OPERATE?
•SURGERY IS THE LAST RESORT
• Good spine surgeons exhaust all other necessary options
• The act of operating is wrought with risks
• Want to be sure to have good outcomes, the indications and outcome shouldn’t
be the risk laden part
• Must have right indications for operating
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ADVANCEMENTS IN TREATMENT
• Herniated discs → if fail conservative pain management,
have minimally invasive outpatient procedures to perform
microdiscectomies
• Axial back pain → If fail conservative pain
management, we have minimally invasive techniques for
facet arthropathy and degenerative disc disease including
disc replacement and not fusion.
• Debilitating compression fractures → if fail conservative
management have MIS outpatient kyphoplasty treatments
• SI joint pain → If fail conservative management. Have
outpatient MIS treatments.
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PROBLEMS THAT WE HAVEN’T RESOLVED
• Adjacent level disease
• How do you stress shield the disc above or below
a treated spinal level, so it does not fail sooner?
• Medical treatment for the prevention of
degenerative spine changes
• Restorative treatments for degenerative
spine changes
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ALGORITHM OF TREATMENT
• Common algorithm of spine related conditions
• Neck/back or extremity pain → active treatment by the patient (OTC pain
meds, patches, creams) → Resolved
• See family/primary care provider → Treat conservatively (OMT, Pain meds)
→ Resolved
• Imaging (XR, CT, MRI)→ Continue non-operative management or Pain
management → Spine surgeon
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COMMON AILMENTS AND TODAYS SURGICAL TREATMENTS
• Radiculopathy
• Neurogenic Claudication
• Axial Back Pain
• Compression Fractures
• SI Joint pain
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RADICULOPATHY/ SCIATICA /HERNIATED DISC
• Usually from nerve root compression
• Can be from disc herniation or foraminal stenosis
• Dermatomal in nature
• Usually dermatomal sharp shooting pain in acute phase.
• Can be dull achy pain usually in chronic phase
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• Classically a paracentral disk herniation
• Can also be from foraminal collapse, facet joint overgrowth, or a far lateral
disk herniation
• Diagnostic testing would include MRI, CT scan (looking for osseous pathology),
or a CT myelogram if can’t have an MRI
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SURGICAL TREATMENT
Goal of surgery
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ENDOSCOPICALLY
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NEUROGENIC CLAUDICATION/LUMBAR STENOSIS
• Unilateral or bilateral leg pain, numbness, or weakness usually while standing
or walking
• Physical exam can be normal
• Usually symptom improvement with flexion of spine
• Distinguish from vascular claudication
• Improve with rest and not flexing forward.
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WORK-UP
• MRI, CT, myelogram
• Can be caused by:
• congenital canal stenosis
• Disk bulge
• Ligamentum flavum hypertrophy
• Facet joint overgrowth
• spondylolisthesis
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TREATMENT
• Conservative treatment:
• OMT
• Epidural injections
• Physical therapy
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SURGICAL THERAPY
• Standard therapy involves a midline laminectomy and foraminotomy
• New therapies include indirect decompression with an interspinous spacer
device, causes focal flexion and stretching of the ligamentum flavum and facet
joint
• I recommend with caution - The focal flexion can cause other issues including DDD, and
kyphosis with loss of sagittal balance
• Minimally invasive hemilaminectomy with bilateral ligamentum flavum resection
and decompression
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Goal of Surgery
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Minimally invasive
tubular retractor
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INTERSPINOUS SPACER DEVICE
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AXIAL BACK PAIN (DEGENERATIVE DISEASE)
• Pain that worsens with activity and lessens
with rest.
• Anterior thigh pain can be associated with
low back pathology due to somatotopic
pattern
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SOMATOTOPIC
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WORK UP MRI to
examine disk
and
neighboring
structures
CT myelogram
when MRI not
possible
Flexion-
Extension XR to
R/O
spondylolisthes
is
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NEUROIMAGING
• Develop black disc due to loss of disc water content
• Loss of disc height
• Modic end plate changes (high T2 signal) in the sandwiching boney endplates
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DEGENERATIVE DISC CHANGES
Acute
edema
Fatty marrow
Sclerosis
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TREATMENT
• Conservative Treatments:
• OMT
• Physical therapy – core strengthening exercises
• ESI
• Surgery if all else fails
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SURGERY
• Theory of surgical intervention rests on notion that movement and motion of
that spinal segment causes pain.
• Aims to eliminate motion in that disc level known as fusion.
• Many ways to perform
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APPROACHES TO THE SPINE
• ALIF - Good for restoring
height and lordosis
• OLIF – Less risk of vascular
injury, restore height
• XLIF– less risk of vascular
injury, restore disk height
• PLIF- single stage/position
surgery, address posterior
pathology
• TLIF– single stage/position
surgery, address posterior
pathology, less retraction
than PLIF
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OPEN VERSUS MINIMALLY INVASIVE
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END RESULT
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FINAL PRODUCT
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COMPRESSION FRACTURES
• Can be pathological or traumatic or insufficiency
• Common in aging population
• Pathologic usually from tumor – Find source (Primary vs. Mets)
• Treatment is decompressive spine surgery if necessary or radiofrequency ablation and
cement kyphoplasty along with systemic treatments of chemo and radiation
• Traumatic or insufficiency fracture – Treat with conservative pain management
and bracing
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WORK UP
• Imaging to determine acuity of fracture
• Percutaneous Vertebral Augmentation (kyphoplasty) good option in acute and
subacute fractures
• Best indicator of acuity is MRI → Hypointense T1, Hyperintense T2 and
positive STIR.
• Can have 80-90% improvement in pain.
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PERCUTANEOUS VERTEBRAL AUGMENTATION (KYPHOPLASTY)
• Can be performed outpatient
• Can be performed with general anesthesia, light sedation or local anesthesia
• Objective is pain relief and stabilization
• Increased activity level and decreased dependence on opioids.
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IF CONSERVATIVE PAIN
TECHNIQUES FAIL →
BALLOON KYPHOPLASTY
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SACROILIAC (SI) JOINT PAIN
• 15-20% of axial low back pain patients have SI joint pathology.
• Characterized by upper buttock pain just below the level of the posterior
superior iliac spine (PSIS), especially with positional changes.
• From siting going to standing.
• Climbing or descending stairs
• Single-leg stance
• Provocative tests can be performed
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SI JOINT PROVOCATIVE TESTS
• FABER = Flexion,
Abduction, External
Rotation
• 2 - 3 positive tests
indicative of SI Joint
Pain→ OMT and
physical therapy
+/- SI Joint
injection/block
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SI JOINT TREATMENT
• If conservative management including OMT,
SI Joint strengthening exercises fail and the
patient has at least 70% relief from two
separate SI Joint blocks then they are a good
candidate for SI Joint Fusion
SI-Bone ifuse implant
system
Medtronic Rialto implant
system
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CUTTING EDGEROBOTIC ASSISTED SPINE SURGERY
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CUTTING EDGE
• Endoscope assisted
surgery
• Use an endoscope to
perform disc work and
placement of spacer
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REFERENCES
• Handbook of Spine Surgery, 2016, 2nd edition, thieme publication
• SI-Bone ifuse implant system
• Medtronic Rialto implant system
• Greenberg, Handbook of Neurosurgery, 7th edition, thieme publication.
• Thieme MedOne medical resource
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