Neurosurgery

Kyphoplasty

Click here for more information: www.kyphon.com/us/patient.aspx

Head and Neck Surgery

We are currently gathering our resources for this section. Please check back again soon!

Spinal Instrumentation Surgery

We are currently gathering our resources for this section. Please check back again soon!

Anterior Lumbar Interbody Fusion

The anterior lumbar interbody fusion (ALIF) is similar to the posterior lumbar interbody fusion (PLIF), except that in the ALIF the disc space is fused by approaching the spine through the abdomen instead of through the back.

In the ALIF approach, a three-inch to five-inch incision is made on the left side of the abdomen and the abdominal muscles are retracted to the side.

Since the anterior abdominal muscle in the midline (rectus abdominis) runs vertically, it does not need to be cut and easily retracts to the side. The abdominal contents lay inside a large sack (peritoneum) that can also be retracted, thus allowing the surgeon access to the front of the spine.

Some ALIF procedures will be done using a minilaparotomy (one small incision) or with an endoscope (a scope that allows the surgery to be done through several one-inch incisions).

The minilaparotomy allows better visualization and can be done with a minimal amount of postoperative pain. Most surgeons do not use the open, minilaparotomy approach.
The endoscopic approach has more limited visualization, and it usually leads to larger surgical times and carries with it a much higher technical learning curve for the surgeon.

The results with either procedure are equivalent and the type of approach used should depend mostly on which procedure the surgeon is most comfortable using.

The large blood vessels that continue to the legs (aorta and vena cava) lay on top of the spine, so many spine surgeons will perform this surgery in conjunction with a vascular surgeon who mobilizes the large blood vessels. After the blood vessels have been moved aside, the disc material is removed and bone graft, or bone graft and anterior interbody cages, is inserted.

The ALIF approach has the advantage that, unlike the PLIF and posterolateral gutter approaches, both the back muscles and nerves remain undisturbed. Another advantage is that placing the bone graft in the front of the spine places it in compression, and bone in compression tends to fuse better. However, there is also a major risk that is unique to the ALIF approach. The procedure is performed in close proximity to the large blood vessels that go to the legs. Damage to these large blood vessels may result in excessive blood loss. Quoted rates in the medical literature put this risk at 1% to 15%.

For males, another risk unique to this approach is that approaching the L5-S1 (lumbar segment 5 and sacral segment 1) disc space from the front has a risk of creating a condition known as retrograde ejaculation. This condition causes ejaculation to go up into the bladder instead of out. The sensation of ejaculating is largely the same, but it makes conception more difficult. Fortunately, retrograde ejaculation happens in less than 1% of cases and tends to resolve over time (a few months to a year).

Anterior Cervical Decompression

A cervical discectomy may be performed to alleviate nerve pinching (cervical disc herniations). This procedure allows the offending disc to be surgically removed.

The anterior approach (from the front of the neck) can provide exposure from C2 down to the cervico-thoracic junction. Surgeons often prefer it because it provides good access to the spine through a relatively uncomplicated pathway.

After a skin incision is made, only one thin vestigial muscle needs to be cut, after which anatomic planes can be followed right down to the spine. The limited amount of muscle transection or dissection helps to limit postoperative pain.

The general procedure is:

1. Surgical approach

The skin incision is about one inch and horizontal and can be made on the left or right hand side of the neck
The thin platysma muscle is then split in line with the skin incision and the plane between the sternocleidomastoid muscle and the strap muscles is then entered
Next, a plane between the trachea/esophagus and the carotid sheath can be entered
A thin fascia (flat layers of fibrous tissue) covers the spine (pre-vertebral fascia) which can easily be dissected away from the disc space

2. Disc removal

A needle is then inserted into the disc space and an x-ray is done to confirm that the surgeon is at the correct level of the spine.
After the correct disc space has been identified on x-ray, the disc is then removed by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus pulposus (the soft inner core of the disc)

3. Dissection

Dissection is carried out from the front to back to a ligament called the posterior longitudinal ligament. Often this ligament is gently removed to allow access to the spinal canal to remove any osteophytes (bone spurs) or disc material that may have extruded through the ligament.
The dissection is often performed using an operating microscope to aid with visualization of the canal.

Possible risks and complications of anterior cervical discectomy may include:

Nerve root damage
Damage to the spinal cord (about 1 in 10,000)
Bleeding
Infection
Graft dislodgment
Damage to the trachea/esophagus
Continued pain

Also, the small nerve that supplies innervation to the vocal cords (recurrent laryngeal nerve) will sometimes not function for several months after surgery because of retraction during the procedure, which can cause temporary hoarseness. Retraction of the esophagus can also produce temporary difficulty with swallowing (1 to 2 weeks).

There is little chance of a recurrent disc herniation because most of the disc is removed with this type of surgery.

An anterior cervical fusion is usually done as part of a cervical discectomy in order to jack open the disc space to prevent disc space collapse (kyphosis).

Lumbar Laminectomy

Similar to a microdecompression, a lumbar laminectomy (open decompression) is a surgical procedure that is performed to alleviate pain caused by neural impingement. The surgery is designed to remove a small portion of the bone over the nerve root and/or disc material from under the nerve root to give the nerve root more space and a better healing environment.

A laminectomy is effective to decrease pain and improve function for patients with lumbar spinal stenosis. Spinal stenosis is a condition that primarily afflicts elderly patients, and is caused by degenerative changes that result in enlargement of the facet joints. The enlarged joints then place pressure on the nerves, and this pressure may be effectively relieved with a lumbar laminectomy.

Surgical procedure

The laminectomy (open decompression) differs from a microdiscectomy in that the incision is longer and there is more muscle stripping.

First, the back is approached through a two-inch to five-inch long incision in the midline of the back and the left and right back muscles (erector spinae) are dissected off the lamina on both sides and at multiple levels.
After the spine is approached, the lamina is removed (laminectomy) which allows visualization of the nerve roots.
The facet joints, which are directly over the nerve roots, may then be undercut (trimmed) to give the nerve roots more room.

Post-operatively, patients are in the hospital for one to three days, and the individual patient’s mobilization (return to normal activity) is largely dependent on his/her pre-operative condition and age. Directly following the procedure, patients are encouraged to walk. However, it is recommended that patients avoid excessive bending, lifting or twisting for six weeks in order to avoid pulling on the suture line before it heals.

The success rate of a laminectomy surgery is favorable. Following surgery, approximately 70% to 80% of patients will have significant improvement in their function (ability to perform normal daily activities) and markedly reduced level of pain and discomfort. The surgical results are much better for relief of leg pain caused by spinal stenosis, and not nearly as reliable for relief of lower back pain.

Unfortunately, the symptoms may recur after several years as the degenerative process that originally produced the spinal stenosis continues.

Risks and potential complications with a laminectomy procedure are largely the same as for a microdiscectomy and include dural tear (cerebrospinal fluid leak), nerve root damage, bowel/bladder incontinence, bleeding, or infection.

In addition, lumbar laminectomy carries a few added potential complications because it is a larger procedure, and greater proportions of elderly patients have this procedure. Post-operatively, there is also the added risk of a slipped vertebral body (postlaminectomy spondylolisthesis) if the remaining bones are not strong enough to support the spine.

Decompression/Microdiscectomy

In a microdecompression, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and provide more room for the nerve to heal. A microdecompression is typically performed for lumbar disc herniation and is called microdiscectomy.

A microdiscectomy surgery is actually more effective for treating leg pain (radiculopathy) than for back pain. The impingement on the nerve root (compression) can cause substantial leg pain, and while it may take weeks or months for the nerve root to fully heal, and any numbness or weakness get better, patients normally feel relief from leg pain almost immediately after microdiscectomy surgery.

A microdiscectomy is performed through a small (1 to 1 1/2 inch) incision in the midline of the low back. First, the back muscles (erector spinae) are lifted off the bony arch (lamina) of the spine. Since these back muscles run vertically, they can be moved out of the way rather than cut. The surgeon is then able to enter the spine by removing a membrane over the nerve roots (ligamentum flavum), and uses either operating glasses (loupes) or an operating microscope to visualize the nerve root.

Often, a small portion of the inside facet joint is removed both to facilitate access to the nerve root and to relieve pressure over the nerve. The nerve root is then gently removed to the side and the disc material is removed from under the nerve root. Importantly, since almost all of the joints, ligaments, and muscles are left intact, this procedure does not change the mechanical structure of the patient’s lower (lumbar) spine.

In general, if a patient’s leg pain due to a disc herniation is going to get better, it will do so in about 6-12 weeks. As long as the pain is tolerable and the patient can function adequately, it is generally advisable to postpone surgery for a short period of time. Microdiscectomy surgery is typically recommended for patients who have experienced leg pain for at least 6 weeks and have not found sufficient pain relief with conservative treatment (oral steroids, anti-inflammatory meds, and physical therapy). However, these complications are quite rare. A dural tear, which occurs in 1-2% of these surgeries does not change the results of surgery, but post-operatively the patient may be asked to lay recumbent for one to two days to allow the leak to seal.

Carotid Endarterectomy

We are currently gathering our resources for this section. Please check back again soon!

Carpal Tunnel Procedures

We are currently gathering our resources for this section. Please check back again soon!