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Minimally Invasive Technology

Spine surgery, like other aspects of medicine, is moving more towards minimally invasive techniques and innovative ways of approaching the common problems that patients suffer in the neck and back. Just in the last 10 years, there have been significant improvements in techniques to improve outcomes and shorten recovery times so critical to patients when considering elective surgeries. Minimally invasive procedures use techniques and instrumentation to allow smaller incisions, less muscle disruption, and less blood loss resulting in faster recovery. At Sonoran Spine, minimally invasive surgery (MIS) really isn't a product, but a philosophy that we pursue to limit recovery time and complications in our patients.

Help for a Disc Herniations through a Smaller Incision

The original minimally invasive procedure, microdiscectomy, is used to treat a herniated disc that causes leg pain or sciatica. Using MIS, the disc herniation can be removed through a less than one inch incision. The limited muscle disruption allows this surgery to be done as an out-patient compared to longer hospital stay. Some single level disc herniations in the cervical spine (neck) can also now be done as an out-patient. Both of these more familiar surgeries are still done in a traditional way, but refined techniques allow our patients to recover quickly without hospitalization and with less pain.

Faster Recovery for Lumbar Fusion Surgery

The most exciting type of minimally invasive surgery is the lumbar fusion surgery (surgical technique used to join two or more vertebrae together that stops movement between them) and sometimes, the laminectomy (the removal of the lamina or portion of the vertebral bone in the spine) that corrects a pinched nerve. There are many patients that qualify for these newer minimally invasive approaches that limit blood loss, allow less hospital stay time, and faster recovery to full activity. Traditional pedicle screws to stabilize and brace the spine in the area that two vertebrae are to be fused typically require disruption of the muscle at the spine. Now, screws can be placed through 1-1 ½ inch incisions with virtually no blood loss during the procedure. Using the same incision, a fusion of a disc space can done at the same time with the same success. Minimally invasive fusion surgery decreases a hospital stay from four to 2 or 3 days, cuts blood loss half, decreasing the need for a postoperative blood transfusion. Recovery time for returning to work or full activity with minimal restriction is typically decreased by 20 to 30%.

More Options for Spine Surgery

Even lumbar disc fusions that require anterior (from the front of the body) abdominal approaches with higher bleeding risks can now be done through smaller incisions of 2-3 inches vs. 6-8 inches in length. At certain levels the same surgeries can be done by approaching the disc from the side through a ½ inch incision and significantly less risk for blood loss as well.

These techniques continue to evolve and the physicians at Sonoran Spine are taking the lead to improve our patients' risk profile and decrease recovery time back to an active lifestyle. We may not be able to treat every condition with these techniques, but most patients are surprised with the number of options that are now available from which to choose.

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Solutions for Back Pain

If you have never experienced back pain, odds are one day you will. The big question is, HOW ACTIVE DO YOU WANT TO BE? What if your back pain stays roughly the same, where do you see yourself ten years from now? For most people, a completely sedentary lifestyle spent sitting on the couch with a remote control in hand is not a reasonable alternative. For motivated patients wanting to get their life back again, there are several pathways to achieving a higher level of function with less pain. Here at Sonoran Spine, we have experience and expertise in spine. In fact, it is all we do.

A Wellness Approach

For some patients, a wellness approach with primary focus on healthy lifestyle, proper diet and nutrition, and a daily exercise program is ideal. Many people seek out treatment from nontraditional sources such as chiropractic and acupuncture. These can be helpful at treating specific and nonspecific causes for pain in many patients. We have also seen significant improvements in baseline pain for patients who regularly participate in yoga. Pilates and other similar exercise programs have also been helpful in many of our patients.

Conservative Options

For other patients, focused and supervised physical therapy from a quality spine physical therapist is the best way forward. For these patients, often the wellness approach has been tried and the expertise of a spine focused physical therapist can be invaluable. Antiinflammatory medications and a daily exercise program added to the work of the physical therapist is often all that is needed to feel better or at least live with back pain.

Should Surgery Be Considered?

When back and neck pain become problematic, it is imperative that a specific diagnosis be obtained so that treatment can be focused at treating the specific diagnosis. Patients with nerve root compression caused from a disc herniation are very different than patients with nerve root compression caused from degenerative spinal stenosis. Both of these groups can be helped with therapy, and often an epidural steroid injection.

If your diagnosis includes a spinal instability secondary to arthritis, a slipped vertebra, fractured vertebra or other conditions that causes activity-related back pain, you may require some type of surgery to stabilize the part of your back that is affected. If this is required, we have long-term data that shows 85 to 90% of our patients return to a high level of functionality. Patients with spinal curvature, patients who are stooped or bent over, or patients with congenital or developmental spinal deformity can be dramatically helped through surgical correction of the deformity and stabilization of the spine restoring a new and improved posture.

Getting Your Life Back

So, the question remains, how active do you want to be? Where do you see yourself in ten years? If your pain is bothersome enough, you deserve a clear diagnosis, a treatment program tailored to your particular problem, and the optimal chance for improvement with expert therapy and treatment. We have high expertise for treatment of spinal disease, whether in the arena of wellness, acupuncture and yoga, formal physical therapy, medication and a home exercise program, or surgical correction of problems that will not respond to anything else. Our long term research has been presented at national and internal meetings and published in major spine journals. Our work is presented to spine specialists worldwide along with our research data shows that excellent outcomes are achievable in most patients with most conditions, when the diagnosis is correctly made and treatment is correctly applied. There are many solutions for back pain, depending on the underlying cause. Our goal is to analyze your particular problem and help you find the solution to a higher level of function and less pain for a happier and more productive future.

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Artificial Disc Replacement

The Emergence of Artificial Disc Replacement

artificial_diskMore than 80% of Americans will experience significant back pain at least once in their lives. The personal and monetary impact can be staggering. A major cause of back pain is the degeneration of the shock absorbers, discs that are positioned in between the bony vertebral bodies of the spine. disc degeneration can be painful and often difficult to treat long term. A promising surgical option recently approved by the FDA is the use of artificial discs.

The Spinal Disc

Spinal discs lie between the vertebrae in our spines, serve as shock absorbers, and allow range of motion. However, as early as in our 30's, these discs begin to lose their water content and then degenerate. This results in disc flattening, tearing or fraying which can irritate nerve endings resulting in back pain. We are not sure why some people experience these changes earlier than others although there is evidence that genetic influences, environmental stresses and accumulations of major and minor trauma can contribute to a painful disc.

Conservative Treatment Options

Initial treatment for a painful disc is always conservative care. Acetaminophen (Tylenol) or non-steroidal anti-inflammatory medications such as aspirin or ibuprofen can be helpful at reducing the back pain. Sometimes it is necessary to take a prescribed anti-inflammatory medication. It can be helpful to undergo trunk strengthening exercise programs in physical therapy since this approach can also reduce pain and help slow the degenerative process. Exercise programs must be continued on a regular basis to make a long term difference. As the trunk muscles become stronger, some of the load across the spine is alleviated and patients feel less back pain. For most patients, their pain and function are improved with nonoperative care to the point that they can lead a reasonably normal life. Unfortunately, a conservative treatment is not always successful at relieving pain and restoring function, which leads to the next step of surgical intervention. Up until this point, the surgical solution meant spinal fusion surgery. Recently, there is also artificial disc replacement surgery for select patients.

Minimally Invasive Procedures

For the small percentage of patients who fail conservative treatments, the minimally invasive options are limited. There is no FDA approved method of effectively reinflating the worn-out disc. Hopefully, this will be an option in the future. Recent interventions include Intra-discal Electrothermal Therapy (IDET) (1997). IDET involves inserting a probe into the affected disc and heating up the outer core of the disc space to 90 degrees (Celsius) for 15-20 minutes in an effort to cauterize tiny nerve endings in the disc, making them less sensitive to pain. Results have been limited, with the latest studies showing only 33-50% patient satisfaction at one year follow up.

Surgical Options

Surgical options for patients with degenerative disc disease who are deemed surgical candidates (not everyone with degenerative discs is a surgical candidate) involve removing the affected disc(s) and either: 1) Fusing the affected segment(s) or 2) Inserting an artificial disc.

Spinal Fusion

The mainstay of surgical treatment for patients with degenerative disc disease who have failed 6-12 months conservative care is to fuse the painful level(s). Spinal fusion entails stopping the motion at a painful motion segment (the joint formed by two vertebral bodies). Fusion takes place by placing bone in between the vertebral bodies. As the bone grows, it fuses the vertebrae together, thus, eliminating the motion at a specific level. Success rates with fusions performed for degenerative disc disease range in the literature between 65 and 93%. It has become the standard of care for discogenic pain and is often very effective in relieving pain.

Bone grafting is required for spinal fusion. The standard in spine surgery is harvesting bone from the patient's pelvis at the time of surgery. However, to improve healing and reduce risk of chronic pain at the bone graft site, other alternatives are now being used. Bone morphogenic protein (BMP) is now frequently used to enhance healing of the fusion. It not only improves the fusion rate but increases its success and often eliminates the need for harvesting bone graft.

Spinal fusion does have its drawbacks. First, the bone does not always heal or "fuse" correctly. A spinal fusion at one or more levels causes stiffness and decreased motion of the spine. Spinal fusion at one or more levels can increase the stress to the rest of the spine. Because of these problems, alternative treatment options such as the artificial disc have been pursued.

Artificial Disc Replacement

Based on the success of other joints in the body successfully treated with joint replacement, efforts began in Europe back in the 1980's to develop an artificial disc replacement. The potential benefit of the artificial disc is to preserve motion of the operated segment allowing the patient more flexibility to bend forward, backward, and rotate or twist. It is also hoped that adjacent levels of the spine will be less likely to become arthritic.

One of these, the SB Charite (Germany) artificial disc, recently completed Food and Drug Administration (FDA) clinical trials and received final approval in the Fall of 2004. Results from the FDA 2 year follow-up were as successful as an anterior fusion. A patient satisfaction survey showed a significant superiority of the Charite group over the fusion group. At 24 months, 88% of patients implanted with the Charite Artificial disc expressed satisfaction with the procedure, compared with 81% of fusion patients. On average, patients implanted with the Charite Artificial disc were discharged from the hospital a half-day sooner than fusion patients.

The materials, cobalt chromium (endplates) and ultra-high molecular weight polyethylene (sliding core) used in the Charite are similar to those used in hip and knee replacements. Patient selection is key to successful artificial disc replacement. Patients must have failed at least six months of conservative treatment such as pain medication or physical therapy. The typical patient is between 18 and 60 years old and has degenerative disc disease between L4-5 and/or L5-S1 with less than 3mm of vertebrae slippage. Candidates suffer from low back pain as the major complaint (rather than leg pain).

The disc is designed to restore disc space height, restore disc flexibility, prevent disc degeneration at adjacent segments and reduce or eliminate pain from motion and improve a patient's functional activities.

The surgical time it takes to implant an artificial disc is similar to that of a fusion, but the procedure is done from the front, as opposed to most fusions which are performed from the back. Typical hospital stay is between 2-4 days, and patients typically have minor motion and lifting restrictions for 6 weeks. These restrictions are less than with a spinal fusion.

Unlike spinal fusion, artificial disc replacement does not yet enjoy long-term follow up results. Considering the young age of most recipients, there is some concern over the long term success rate of these implants. The good news is that if the implant fails to eliminate pain or if the patient develops debilitating pain in the facet (adjacent small joints in the spine) joints, the patient can still undergo a fusion to alleviate the pain.

Artificial disc replacement is an exciting new development. It is a new tool available to certain patients and their spine surgeons to address chronic low back pain due to degenerative disc disease. Research has shown that it can be a benefit to those candidates who have failed conservative management and fit the criteria for patient selection. For more information, you should be evaluated to discuss your options.

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Kyphoplasty vs. Vertebroplasty

What's the Difference?

kyphoplasty1One of the biggest problems with osteoporosis (soft bones) is the development of bone fractures of the spine, hip, and wrist. Of these, spinal compression fractures are the most common, affecting 700,000 Americans each year. These fractures occur when the bone strength is diminished to the point that even minor trauma causes the vertebra to crush. Compression fractures can cause spinal deformity, severe back pain and loss of height. Traditional treatment of compression fractures has included bedrest, pain medications, bracing, and in rare cases surgery. Surgical treatment has been an option of last resort because of the long recovery, poor outcome, and risks. It was only considered in cases of spinal cord compression and for the most significant deformity. Patients with compression fractures secondary to osteoporosis or cancer usually have other medical illnesses. They require a treatment that would allow immediate pain relief, minimal stress on their health, and allow them to return to a full level of activity. Recently two minimally invasive surgical techniques have emerged, Kyphoplasty and Vertebroplasty, as potential answers to the problems posed by osteoporotic compression fractures of the spine.

Vertebroplasty was developed in the mid 1980's by a radiologist in France. It was embraced for use in the USA in the mid 1990's. Kyphoplasty was first described in 1998 by a Berkley California orthopedic surgeon. Let's compare the two procedures, their similarities and differences, and their respective risks and long term prospects for benefit in patients with osteoporosis related compression fractures. 

 Vertebroplasty

Vertebroplasty begins with the introduction of a needle into the collapsed vertebra under xray guidance. The vertebral body, or front portion of the spine bone, is then injected with bone cement. In order for the cement to be able to enter into the bone, the cement must be in a liquid state and high pressure must be used to push it through the needle. The liquid state cement hardens over a period of 12-15 minutes secondary to a chemical reaction. Once the cement is hard, the bone is stable and immediate weight bearing can be resumed. The French and some American studies found 70 – 90% of patients experienced pain relief.

 The problems with Vertebroplasty are two fold. The first is the liquid cement will follow the path of least resistance. Best case scenario is that the collapsed vertebra has a hard outer surface (cortex) of the bone being intact to contain the cement as it is being injected. If there is any defect in the vertebra wall, there is a risk of cement leaking into the spinal canal or into the abdomen or chest. Cement entering into areas that were unintended in an uncontrolled fashion has led to problems in some of these patients, including liquid cement migrating to the lungs or into the spinal canal to compress the spinal cord. The second problem with Vertebroplasty is both a short and long term one. The cement fills the broken vertebra, freezing the spine in its collapsed position. We are all familiar with people who have progressively become “hunched over” with time, often secondary to multiple compression fractures. Vertebroplasty does not address the deformity issue nor prevent patients from becoming hunched over. 

 Kyphoplasty

Kyphoplasty was developed by an orthopedic surgeon to straighten the broken or collapsed vertebra and address the issue of becoming hunched over. One of the basic principles of orthopedics is to straighten or correct broken bones. In other words, "If it''s bent, straighten it ou". Kyphoplasty begins similar to Vertebroplasty, with a needle introduced into the fractured vertebral body. However, that is where any similarity ends. Kyphoplasty calls for insertion of a small tube over the needle. Through this tube, a balloon tipped catheter is inserted into the broken vertebra. The balloon is slowly inflated. With new fractures, inflation of the balloon raises up the collapsed vertebrae to its normal height. More importantly, the balloon creates a space in the bone as it inflates. This space allows for cement to be placed at low pressure and thicker, putty like consistency. This substantially reduces the risk of cement leaking out of the bone. Kyphoplasty patients also describe immediate relief from fracture pain. In our series at the Sonoran Spine  published in The Spine Journal last year, we saw pain improvement in 90% of our patients.

Both Vertebroplasty and Kyphoplasty allow surgeons to treat compression fractures through a minimally invasive procedure. Both relieve the pain caused by the vertebral fracture. Only Kyphoplasty allows for correction of the collapsed vertebra and decreases the risk of the patient becoming hunched over. Adding a safer placement of the cement into the fractured vertebra makes Kyphoplasty our clear and safer choice for patients who are suffering from osteoporotic compression fractures.

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Minimally Invasive Surgery (Are You A Candidate?)

jeep_surgery1Only ten years ago if you had spine surgery, you could expect a long recovery, in some cases, as much as a year. Now, thanks to minimally invasive surgery (MIS), what used to result in a week long hospital stay has been reduced to a few days or less. Recovery time has decreased from a few months to a few days and while there used to be long incisions, now it consists of a few small scars. Minimally invasive can mean faster recovery, shorter hospital stays, less blood loss during surgery, reduced pain and the need for pain medication postoperatively.

Minimally invasive surgery utilizes techniques that decrease injury to the muscles and other soft tissues. The surgery performed under the skin is very similar to that which is performed by traditional techniques. To perform these surgeries safely, we utilize varying technologies to visualize the spine including the naked eye, microscopes, radiography, and endoscopes.

Orthopaedic surgeons have used minimally invasive surgery in other parts of the body since the 1970s. General surgeons pioneered laparoscopy for abdominal surgery to minimize the trauma caused to patients. Now the majority of gall bladder surgery and many hernias, appendectomies and some intestinal surgeries are performed through the scope. Cardiothoracic surgeons use smaller incisions to harvest a vein during open heart surgery. All of these improvements are done to minimize tissue damage and incision scarring to ultimately improve the patient's outcome resulting in the patient's return to daily activities and employment.

MIS can not be used with all forms of spinal surgery nor is it appropriate for all patients. Although we continue to improve the field of minimally invasive surgery, it is continuing to rapidly evolve. We now can repair herniated discs. We can perform spinal fusion, which is used on degenerative discs and we can perform some deformity corrections such as for scoliosis. Finally, we can restore a fractured vertebra with a procedure called Kyphoplasty. MIS is on the move, all to the benefit of the patient. Let's be specific about some of these procedures. 

Minimally Invasive Fracture Reduction (Kyphoplasty)

The majority of vertebral compression fractures are a result of osteoporosis. Now there is a way to restore the height of the vertebral body as well as eliminate the pain of the fracture. Through two small incisions, we can create narrow pathways into the fractured bone and insert two tiny balloons. The balloons are inflated to restore the bone to its original shape. Once this has been done, the balloons are deflated and removed and bone cement is inserted. The pain from the fracture and surgery is gone within a few days.

Kyphoplasty can be performed on compression fractures that have not fully healed in their current position. The procedure is usually done under general anesthesia, takes about 30-45 minutes and an overnight stay in the hospital. The next day you can fully resume your normal activities. 

Minimally Invasive Spinal Fusion

Spinal fusion surgery is performed in an attempt to decrease pain caused by arthritis or painful degenerative discs. Most of these surgeries are performed via a midline incision in the area of concern. The surgeon lifts the spinal muscles off of the bone and proceeds to bone graft the area followed by placement of screws and rods. Recovery from this type of surgery can take several months.

Minimally invasive fusion utilizes smaller incisions located over the area of the screw and rod placement. Under the skin, screws, rods and bone grafting are performed; however, the injury to the muscles is significantly reduced. Blood loss is significantly less as well as the need for pain medication. One can return to full time employment within weeks compared to much longer recovery times with traditional fusion surgery. 

Laminectomy

Similar to minimally invasive fusion surgery, we can now decompress pinched nerves from spinal stenosis with MIS. When spinal fusion is not necessary, it's possible to have the surgery with minimal tissue injury and be discharged the same day as surgery. This can also be performed in conjunction with the minimally invasive fusion. Again, pain is minimal with this approach. 

Discectomy

The discectomy is now commonly done using this approach as well. Muscle injury is reduced by making the skin incision directly over the herniated disc. During the surgery, the portion of the disk that is irritating the nerve is removed. Patients are usually discharged the same day of surgery. The standard discectomy and the minimal approach both yield excellent results in 90% of patients. 

Expertise at the Sonoran Spine

Not all surgeons are trained in minimally invasive surgery. There is a steep learning curve for these procedures and although there are distinct advantages of these procedures, it is important that your surgeon be totally skilled at these newer techniques. MIS is certainly bringing an exciting future to spine surgery as this field continues to evolve.

The physicians at the Sonoran Spine pride ourselves in being leaders in the field of spinal surgery. We are actively involved in the development and teaching of these minimally invasive techniques. Dr. Crandall has been involved with Kyphoplasty since its inception in this country. He has published several papers about the outcomes of our patients at Sonoran Spine. We are also involved with the development and teaching of minimally invasive fusion surgery for one and two level degenerative disc disease. We are active recruiting surgeons to Phoenix to learn this technique. We are committed to continually improving outcomes from spine surgery. Ask us if these minimally invasive techniques can be utilized in your particular situation.

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