Spinal Surgery

Cervical fusion describes a variety of surgeries performed to join together two or more of the seven bones in the neck. The procedure is performed most commonly for severe arthritis in the neck, disc prolapse and fractures in the neck. Fusion surgeries can be done on the front of the neck, the back of the neck or both. The operation when performed from the front requires the disc between the bones and or a vertebra, to be removed. The gap created is then be filled with the use of specialised medical plastics, metals or biologic material to increase the success of bridging the bones. Occasionally, a piece of bone may even be taken from your waist to help with filling the gap. Medical screws and plates may also be used to stabilise the new construct whilst healing takes place. These are left in place for life.

In modern practice, cervical fusions are performed by spine surgeons who are specially trained in the techniques and use an arsenal of complex equipment to achieve success rates in excess of 95% of cases. These include sophisticated monitoring devices which create early warning systems to minimise or even prevent injury to the spinal cord, and computerised navigational software to guide the surgeon in placing the implants.

Patients have short hospital stays of a few days or less and accelerated rehabilitation programs such that they return to a reasonable activity with minimal delay. Often patients have to wear a cervical brace/collar for a short period following surgery. Even though the fusion surgery removes some of the movement of the neck, this is usually minimal, and balanced by the improved function and pain control gained by the procedure.

There is often discomfort swallowing following the procedure. Unusual complications include nerve or spinal cord injury, hoarseness, injury to the neighbouring organs, excessive bleeding and failure of the fusion procedure.

Content written by Dr Kimani White & Dr Ashish Diwan

Lumbar fusion describes a variety of surgeries performed to join together two or more of the bones in the lower back. The procedure is performed as treatment for several conditions, most commonly including severe arthritis in the back, disc prolapse, scoliosis and fractures in the lower back. Another common condition for which lumbar spinal fusion is performed Spondylolisthesis (slight slipping of the vertebral bodies).

Fusion surgeries are most commonly done from the back but can also be done from the front, the side or a combination of these. While the operations have now been called by numerous acronyms including PSF, PLIF, TLIF, XLIF, DLIF, OLIF, ALIF (Where the acronyms are a combination of P= posterior, S = spinal, F = fusion, L = lumbar, I = interbody, T = transforaminal, X = extreme lateral, D = direct lateral, O = oblique, A = anterior and so on); essentially the operation requires gluing of spinal bones. Part of the intervertebral disc may be removed. The gap created can then be filled with specialised medical plastics, metals or biologic material to increase their success of bridging the bones. Occasionally, a piece of bone may even be taken from your waist or rib to help the bones to heal. Medical grade screws and plates may also be used to stabilize the new construct whilst healing takes place. These may be left in place for life. In modern medical practice, they are performed by spine surgeons who are specially trained in the techniques and use an arsenal of complex equipment to achieve success rates in excess of 85% of cases. These include sophisticated monitoring devices which create early warning systems to minimise or even prevent injury to the spinal cord, and computerised navigational software to guide the surgeon in placing the implants. Patients have short hospital stays of a few days or less and accelerated rehabilitation programs such that they return to a reasonable activity with minimal delay. Occasionally, patients have to wear a lumbar brace/collar for a short period following surgery. Even though the fusion surgery removes some of the movement of the back, this is usually minimal, and balanced by the improved function and pain control gained by the procedure. Unusual complications include nerve or spinal cord injury, injury to the neighbouring organs, excessive bleeding and failure of the fusion procedure.

Content written by Dr Kimani White & Dr Ashish Diwan

When back pain is associated with leg pain or with sciatica spinal decompression or laminectomy or discectomy are performed. Laminectomy describes a surgical procedure performed on the spine to remove the bony coverage (Laminae) at the back of the spinal cord and neural elements in the back. It is performed to access the neural elements (Spinal cords and nerve roots) or to decompress them most commonly from compression caused by age-related arthritic changes. It is often also done to decompress fractures, “slipped discs’, tumours, blood clots or pus. The procedure may be done alone, or it may be combined with other procedures, including removal of the intervertebral disc (Discectomy), instrumentation of the spine (Insertion of implants to support the spine) and fusion of the bones. It may be done in any region of the spine including the cervical (Arm pain with neck pain), thoracic or lumbar spine.

Based on the type of approach your surgeon may use discectomy are known by various names including Microdiscectomy, Endoscopic Discectomy, MED discectomy etc. The short and long term results of all types of discectomy are essentially the same

Content written by Dr Kimani White & Dr Ashish Diwan

Disc replacement describes a surgical procedure to replace the intervertebral disc between two vertebra, with a prosthetic implant which preserves some of its function and movements. The implants usually are made from medical plastics and metals which recreate some of the multi-directional joint movement. Currently, only a few devices are acceptable for use in the procedure. The procedure is performed for arthritic disease located predominantly in the disc but sparing the other tissues. It involves a discectomy, done from the front of the spine, followed by the insertion of the implant. It is an alternative to a fusion procedure which unites the two adjacent bones and sacrifices the motion between them. The procedure is more technical than disc fusion and requires a more stringent set of patient selection criteria. In modern medical practice, they are performed by spine surgeons who are specially trained in the techniques and use an arsenal of complex equipment to achieve success rates majority of cases. As a result, fewer persons are candidates for this surgery than for a fusion procedure. Patients have short hospital stays of a few days of less and accelerated rehabilitation programs such that they return to a reasonable activity with minimal delay. Occasionally, patients have to wear a cervical brace/collar for a short period following surgery. As compared to a fusion procedure, disc replacement removes the diseased disc (and associated painful movements) and replaces it with a painless mobile joint. Unusual complications include nerve or spinal cord injury, injury to the neighbouring organs, excessive bleeding and failure of the fusion procedure.

Content written by Dr Kimani White & Dr Ashish Diwan

Minimally invasive spinal surgery describes a paradigm shift in the approach to surgery on the spine. At the centre of the movement is the concept that is similar, if not better outcomes, can be achieved by doing identical surgeries through smaller incisions and with less tissue damage. Other advantages to the techniques include, less bleeding, less swelling after surgery, earlier rehabilitation and return to work. The procedures are usually performed by specially trained spinal surgeons as they require specialised techniques. Additionally, specialised equipment is required to achieve the same surgical goals through smaller wounds. These equipment include the use of microscopes, endoscopes, lasers, 3D imaging using O-arm, computerised navigation, nerve monitoring as well as special instruments specific for the surgery.

Content written by Dr Kimani White & Dr Ashish Diwan

Sacro-iliac surgery describes a set of surgeries that join the two bones on either side of the sacro-iliac joint (sacrum-the bone attached to the tail bone, Ilium-the bones on either side of your waist). The procedures are usually performed for treatment of painful diseases affecting the joint include arthritis, inflammation, damage from injuries and fractures or post-partum pain. Traditionally, the procedures were performed with “open” techniques, requiring the joint to be partially exposed, prepared for bone grafting, packed with graft and finally stabilized with screws and plates. These traditional techniques were done from the front or the back of the joint depending on the specific circumstances. They were major procedures associated with significant blood loss, post-operative pain, prolonged hospitalization and rehabilitation. Currently, modern medicine has allowed some of these surgeries to be performed with minimally invasive techniques, which do not expose the joint and potentially allow for smaller surgeries, less operative bleeding, less post operative pain, shorter hospital stay and faster rehabilitation. The techniques typically consist of using image guidance to implant bolts across the joint via small stab incisions.

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Deformity surgery in the spine describes those surgeries that aim to correct a mal-alignment (Like scoliosis, Kyphosis, Listhesis, etc) of the spine surgically. They may be required as a result of problems from birth, problems that arise with growth, sequalae of injury and fractures or problems that arise with the aging spine.

To understand the role of deformity surgery, one first needs to understand the aligned, balanced spine. The normal spine should appear straight when viewed from the front (coronal plane). When viewed from the side (sagittal plane) the spine has alternating, oppositely balanced, sequential curves called lordoses and kyphoses. These curves allow the spine to position the head centrally over the feet, in an upright, erect balanced posture. When the spine appears curved when viewed from the front it is described as a scoliosis. Alternatively, loss of the balance between the lordoses and kyphoses, also create mal-alignment as they usually place the head too far forward relative to the feet. The deformity not only causes a cosmetic problem, but also causes the body to use up extra energy to maintain balance. This may cause fatigue and pain in the muscles and ligaments. The loss of balance also creates abnormal and excessive wear on the joints in the spine, which can also cause more pain and premature arthritis. Other problems, related to severe deformity, arise because of structures being squeezed by the deformed bones e.g. nerves, lungs.

Thus deformity surgery is used to correct these mal-alignments and address problems related to cosmesis, chronic pain, arthritis and organs being compressed. This is done by realigning the deformed curves and getting them to join together (fuse) in the straightened position. In modern medical practice, deformity surgeries are performed by spine surgeons who are specially trained in the techniques and use an arsenal of complex equipment to achieve success rates in excess of 90% of cases. These include sophisticated monitoring devices which create early warning systems to minimize or even prevent injury to the spinal cord, and computerized navigational software to guide the surgeon in placing the implants. Typically, the surgeon will obtain imaging of the deformity with a combination or Xrays, CT scans and MRI scans. These are often input into a computer to facilitate computer navigated planning and surgery. Then, the surgery is performed by realigning the spine and then placing a combination of medical plastics, metals, screws, rods and/or plates to fuse the realigned spine until it heals. These implants may be left in place for life. Additionally, biologic material prepared in a lab or bone harvested from the patient is placed beside the spine to help it to heal in its new position. The surgery may be done from the front, side, back of the spine or a combination of these. Additionally, it may be done by an ‘open’ technique, which exposes the entire deformity for correction, or by a minimally invasive technique, which utilizes navigation to minimize the cut required to correct the deformity. When done by an open technique, the procedures can be major and require a longer hospitalization and rehabilitation than when done by a minimally invasive technique. Your surgeon will help you decide which procedure is most suitable. Unusual problems from the surgeries include injury to the nerves or the spinal cord, injury to the nearby organs, excessive bleeding, infection, and failure of the procedure. Whilst most people will be able to return to light work within 4-8 weeks, the healing process continues on for up to 2 years, and major activity (contact sports) may be restricted during this healing period. Occasionally, a brace may be required for a portion of the rehabilitation period.

Content written by Dr Kimani White & Dr Ashish Diwan

Computer navigated surgery describes a revolutionary set of technologies which allow computerized imaging, analysis, projection, and programming to plan or execute surgery. It is a key component in modern surgery and robotic surgery. Computed assisted surgery is usually facilitated by a sequence of steps including 1. Image acquisition 2. Image analysis 3. Image simulation 4. Surgical navigation and optionally, 5. Robotic surgery. The most sophisticated systems have all these steps.

Image acquisition consists of using an imaging modality to enter the patient’s surgical area of interest (e.g. lumbar spine in spine surgery) into the computer’s database. The best images are usually from a computer tomography scan (CAT scan) but plain Xrays, MRI or Ultrasound have all been used. The images may be obtained preoperatively or, more accurately, intraoperatively and multiple modalities may be fused together to make a single database. The imaging may also include surgical instruments and critical markers, which will be integrated into the dataset to facilitate the further 3Dimensional simulation and surgical navigation steps.

In the second phase, the computer analyses the data to reconstruct a 3 dimensional digital dataset of the patient’s anatomy from the imaging. This dataset is a correctly scaled digital representation of the entire scanned area or volume, with correct distances and depths. This will often contain reference markers or instruments (like the “you are here” marker on a building map) to give the surgeon feedback of where the marker on the patient is found in the image. This is the basis on which all the planning and execution will be done.

In the Image simulation phase, the computer uses its 3D reconstruction of the patient’s anatomy to create visual representations, which the surgeon can view, manipulate and even interact with. These may highlight various parts of the anatomy and hide other parts, as decided by the surgeon. Hence, muscles and fat may be hidden to show only the bone, as in the case of spinal surgery. Also, several different views may be shown simultaneously e.g. cross-sectional views from the front, side, top or bottom, in addition to the entire 3 dimensional reconstruction. This allows a realistic view of the patient’s imaged area that would not be available to the naked eye, giving the surgeon “Xray vision”. These images are displayed in real time and hence the surgeon is able to use the computer representation to assess the inner depths of the patient virtually, before even making an incision to see the tissues for himself.

The navigation phase is a continuation of the simulation phase. Here, the surgeon can move an actual instrument near to the patient and see where the virtual projection of that instrument will be in relation to the inner structures of the patient. As the images can be updated real time, the computer provides a live virtual image of the patient and the surgeon’s instrument simultaneously as the surgeon moves the instrument. To enable this the computer is fitted with a camera that can track or “see” specially marked instruments, and include them in its 3D simulations of the patient. Hence the surgeon can use the simulation to accurately “navigate” to a region of interest, making smaller incisions and accurately placing the instrument or implant, even when he cannot see the actual tip of the instrument.

The final phase of computer navigation is that of robotic surgery. In this step, a surgical robot is used to accurately replicate a particular part of a surgery, such as the placement of a screw. Here, an implant is planned and placed in the simulation, and then the computer programming instructs the robot how to accurately and safely place an actual screw in that simulated position, in the real patient. The entire process is monitored by the surgical team, who also perform the remainder of the surgery, as per normal.

These techniques are particularly useful in regions of complex anatomy e.g. the spine, in circumstances where the anatomy is unusual, e.g. deformity surgery or revision surgery. The technique has been shown to increase the accuracy of placement of screws in the spine when compared to other non-navigated techniques. It also allows better planning of surgery, use of smaller incisions and decreases surgical errors.

Content written by Dr Kimani White & Dr Ashish Diwan