Conventional surgical methods
We use those standard surgical methods that have been accepted by the surgical community in general and that studies have shown to be the most effective. This does mean, however, that there would not be opportunities for further development. We are, in fact, involved in researching ways to improve results attained with the existing techniques, instruments and methods, to find new instruments that could make these conventional methods more precise.
Our work encompasses the entire spine, extending to the surgical treatment of:
- Degeneration - changes occurring as the result of wear
- Trauma - injury due to an accident
- Tumors - benign as well as malignant
- Inflammation - resulting in changes necessitating surgery
- Spinal deformities - due to growth anomalies, degeneration or other diseases.
Spinal surgery does not always involve fusion. These are the decompression surgeries performed for freeing the nerve paths from pressure and performed in cases where, out of the three functions of the spine
- protection of the spinal cord
only the third needs to be re-established. In other words no fusion is required when the stabilization of the spine is maintained.
Herniated or slipped disc removal (discectomy) is the simplest and most common form of decompression surgery. The spine region most prone to disc injury requiring this type of surgery is the area containing the last two segments of the lumbar spine. The next most common region for disc herniation is the lower mid-cervical (neck) segment, though, in practice, surgery can usually be avoided here and is seldom necessary. Herniation of the thoracic segment requiring surgery is rarer still.
A similar surgical intervention, the recalibration, is used to re-establish the original dimensions of the spine segment in cases of bony spine compression
If, at the start of surgery, the spine segment to be operated on is found to be unstable or is injured during the decompression phase, the segment must first be stabilized. The goal is to attain bony fusion of either two neighbouring vertebrae or two separate pieces belonging to another vertebra.*
In some cases, bone alone (generally the patient's) can be implanted with no added metal fixation. Here, the patient is fitted with a temporary exterior fixation (corset) to be worn for a few months. Exceptions to this are certain cervical spine operations where the bone implant, in itself, can provide the needed stability until the bony fusion is completed. This usually takes about three months.
Fusion of the lumbar spine, on the other hand, takes significantly longer with most cases requiring internal fixation with metal implants. The results, however, are also better. The patient can resume weight bearing sooner and rehabilitation is better and faster.
In internal fixation, it is essential that the newest, well-tested and certified materials are used. Originally, rust proof steel was the metal of choice. Now titanium is the most commonly used material. The elasticity of titanium strongly resembles that of the bone, it is not as prone to loosening, does not cause chemical, biological or physical reactions within the body and is not corrosive. With the proper surgical techniques, the implants placed within the bone, or near it, should not cause the patient any discomfort.
We see relatively few trauma patients, since in this country accident victims are generally treated in trauma centers and in hospitals with trauma wards. We will, however, accept special cases where only the spine is injured.
The major force that had caused the spine injury destabilized the spine. In order to re-establish the stability, fixation (fusion) must be done, usually involving a larger segment of the spine. The most important purpose of this surgery is the re-establishing of the original structure of the spinal canal, to stop and possibly reverse nerve damage and to preclude paralysis. Time, as well as the surgical methods and techniques used, is critical in the fight against the chance of permanent damage.
The number of tumor surgeries we perform is increasing and becoming a major part of our work. One reason may be that the new and improved methods and techniques at our disposal make it possible now for patients with previously inoperable tumors to be helped surgically and with the added help of oncological treatments, eventually, cured. Another reason may be that the incidence of tumorous diseases is on the increase worldwide.
Basically, tumors are either benign or malignant and either primary, developing initially in the spine, or secondary, having spread, in our cases, to the spine from another, primary site.
Benign tumors, that do not metastasize, usually appear soliter, that is, alone. These do not generally have an affect on life expectancy, but may, however, have an impact on the quality of life (i.e., pain, paralysis, etc.). These tumors need not always be removed and may oftentimes even remain in place during spinal stabilization (interior fixation) surgery.
Malignant spine tumors may also be primary or secondary (metastatic). Malignant primary tumors usually appear soliter and, when operated in time, may be removed in its entirety.
Malignant primary spine tumors may, of course, also metastasize into other organs (i.e., lungs, liver, etc.) in which case, surgery alone would not suffice - oncological treatments would be needed, as well.
In metastasized malignant spine tumors, biopsy results, the number and types of organs involved and the number and size of the tumors determine the stage of the illness and the possibility of surgery. In these cases, the surgeon often finds him- or herself in the difficult position of having to decide whether a Patient should undergo a surgery which, in the end, could prove to have been unnecessary since neither the life span nor the quality of life could be affected by it. Soliter metastasized tumors are treated as primary malignant tumors.
It is possible in tumor cases, with a correctly applied fixation, to perform decompression surgery to re-establish the stability of the spine segment involved. If the tumor destroyed a spine segment then, along with stabilization, the missing segment will have to be substituted with a special bone cement or spacer. This procedure may be applied on a large scale from the removal of a very painful 10-12 mm size tumor to excision of tumors reaching the size of a human head, completely filling the pelvic and sacrum region and requiring also reconstructive plastic surgery.
We have successfully been able to perform total segment resections and substitutions in great numbers, thereby completely restoring, in one session, the spine's three main functions (spinal cord protection, structural support and stability and flexible motion).
No exterior fixation is necessary. The restoration of the spine column's weight bearing ability, allows the Patient to stand the day following surgery. Since only a few segments are involved in the short and very stable internal stabilization (fixation), the segment not only becomes weight bearing, but as the pain level decreases, so does its flexibility return.
d) Inflammation (Infection)
Though we see increasingly more cases of infection, it is still one tenth of the total number of spine tumors cases we see. Just as in tumors, progressive instability results which, in the majority of cases, requires intervention and fixation. The operation has a threefold objective: to eliminate the core of the infection, to stop pressure on the nerve and to re-establish spine stability. This is accomplished with internal fixation and debridement where the infected area is thoroughly cleansed by continued flushing for 5-7 days. This is followed by antibiotic treatment, sometimes continued for months, and in cases of TB, for years. The Patient must be kept under observation and checked regularly. Temporary external fixation is also often necessary.
The most common deformity of the spine is scoliosis which is mostly being treated in other hospitals, especially the Orthopedic Hospital in Pécs, with excellent results. We chiefly concentrate on the correction and treatment of deformities due to birth anomalies, rheumatological diseases and advanced degeneration. Since these deformities are typically progressive in nature and surgery is, in most instances, unavoidable, we strive to prevent as much damage as possible by intervening as early as possible, ideally when the patient is still complaint free.
Minimally Invasive Surgery
The percutaneous or key-hole technique is a very important part of our practice. While it is an invasive method, it is the most risk free. It was developed more than ten years ago and is increasingly becoming the method of choice since every branch of surgery strives to offer the most help with the least damage to its patients.
The percutaneous technique is excellent for diagnostics as well as therapy. By penetrating the body through an opening of just a few millimeters and manipulating the needle inside the body, we can gain invaluable information not possible with other non-invasive methods. It can help us determine the method of treatment or become the treatment itself.
Various diagnostic methods make it possible for us to gain valuable information regarding the body's condition and the status of an illness without in any way damaging or puncturing the body. These are, what we call, the non-invasive diagnostic methods and include the ultrasound (US), thermography, radioisotope, computer tomography (CT) and magnetic resonance imaging (MRI) techniques. The ultrasound is not useful in the diagnosis of spine disorders while, others, such as thermography are not yet medically accepted. The remainder are accepted methods of diagnosis that can be successfully used, however, the information to be gained is limited and in some cases, not enough. Another disadvantage is that the image is static and can only be taken with the patient in the prone position without any weight bearing down on the body. This makes finding the source of pain difficult even with a thorough physical examination, thus, minimally invasive diagnostic methods such as myelography and/or discography may have to be used.
An organic iodized contrast material is injected into the cerebrospinal liquid bounded to check for compressions or deformities on the dura sac which might negatively affect the nerves running through the dura sac and cause pain. Since similar information may be obtained with Ct and MRI scans, myelography has been pushed into the background recently, especially, due to the resting period of several hours required following the examination, possible severe headaches and, though seldom, allergic reactions.
There are some instances, however, where neither MRI nor CT examinations are possible. These are cases where the area to be examined contains previously surgically implanted metal: The magnetization of the metals precludes the use of the MRI and the disturbances affect the quality of a CT. Unfortunately, however, metal that cannot be magnetized also poses a problem since it can also affect the quality of the images and the more metal is present the more the quality is affected. In these cases, myelography can provide very significant information otherwise, perhaps, not attainable.
One of the most important components of the spine and playing a significant role in its three functions - support, motor function, protection - and also most prone to injury, is the intervertebral disc
In most cases, the source of a patient's pain can usually be found by careful history annotation, thorough physical examination and proper diagnostic imaging procedures. In cases, however, where more than one intervertebral disc is shown to be damaged, other supplementary information may be necessary, in which case, discography may help, on the one part, to locate the pain source and to determine the degree of degeneration, on the other.
Contrast media containing iodine is injected into the intervertebral disc which then colors its nucleus. If this procedure does not cause the patient pain, independent of the patient's condition, no surgery of the intervertebral disc is necessary.
If, however, the procedure does cause pain and conservative treatments have proven to be ineffective, surgery might be necessary with the type of surgical intervention decided according to the morphology of the disc. In advanced degeneration, that is serious injury to the intervertebral disc, open surgery might be indicated while, in cases of beginning degeneration, where the structure is relatively well maintained, percutaneous techniques might be the intervention of choice.
Therapy and Diagnosis in One Step
Over the past ten years, musculoskeletal surgery (orthopedics) has very effectively used locally administered anti-inflammatory injections in the treatment of joint, ligament and other inflammatory conditions.
These injections are made up of two components: a local anesthetic and a steroid for decreasing the inflammation. If the former has an immediate short-term effect, its effectiveness is an indication of the proper placement of the medication, thus, aiding in the process of diagnosis. If the steroid component attains the expected pain relief in two to three days, this not only is therapeutic but also a further diagnostic aid. Several areas of the spine may be treated with these procedures, even if only temporarily.
The nerve root block is an injection into the sheath surrounding a nerve root in the spine to decrease pain temporarily and to define it more precisely. The patient is usually able to go home immediately afterwards.
Facet joint injection is an injection given into the sinovial joint or joints. The patient is usually able to go home immediately afterwards.
Epidural block or Sacral Epidural Adhesiolysis (SEA) is an injection given into the spinal canal that might be effective in cases of irradiating lumbar pain. The patient is usually able to return home following a 1-2 hour rest period.
Percutaneous Surgical Methods
The advantage of this type of surgery is that it is performed through tiny incisions, allowing the surgeon to work in a “closed" environment to reach and treat the affected area. The surgeon is guided by an x-ray monitor, an endoscope or surgical navigation system or both. The small incision causes little damage to tissues during penetration, no general anesthesia is required, is usually done under a local anesthetic, or at most, under intravenous narcotics. Another tremendous advantage is the short hospital stay, short rehabilitation period and quick return to normal daily activities.
Because of the relatively small space available to the surgeon for navigating inside the body, the cases to be treated with this method need to be selected very carefully.
Percutaneous Intervertebral Disc Decompression
Intervertebral disc decompression, or the diminishing of pressure, is one of the oldest known surgical procedures.
The intervertebral disc is considered a closed hydraulic area. Partly due to trauma and partly due to genetic predetermination, the wall of the intervertebral disc may weaken, become thinner and, eventually, because of the internal pressure, herniated. The resulting protrusion causes space deficit, limiting the area available for the nerves thus resulting in pressure on the nerves which, in turn, causes numbness, pain, muscle strength deficit and restricted range of motion.
If, during the examination process, we find that diminished pressure within the intervertebral disc and the elasticity of the posterior wall would cause the protrusion to withdraw, then one of the decompression procedures would be indicated. Manual instruments, automatic cutting and aspirating tools or laser may be used through the tiny incision.
Conservative treatment must be tried before any surgery is attempted.
Percutaneous Laser Disc Decompression
Just as in all other treatment procedures, in order for it to be a success, the patient must be chosen carefully. We only perform this procedure when conservative treatment failed. In these cases, the lumbar MRI shows a dehydrated intervertebral disc with its height almost maintained and which physical examination shows to be the source of the complaints. We next perform a discography to confirm the source of pain, to ensure that the wall of the intervertebral disc is not damaged, is thick enough and that its elasticity will allow it to withdraw when the pressure is diminished.
It should also be noted that the nucleus of the intervertebral disc must be completely enclosed and its capacity for absorbing contrast media should not under any circumstances exceed more than twice the considered normal maximum of 2 milliliters.
The procedure has been in use since 1987 with numerous medical reports attesting to its effectiveness but, it is important, however, to have the proper laser equipment with the proper settings. For these surgeries, the following three frequencies are used today: Holmium (2100nm), NdYAG (1064nm) and bisected YAG or ITP (532nm). Considering the tissue absorption curve, the Holmium frequency seems to be the most appropriate because, due to its maximal absorbency in water, its effect within the intervertebral disc can be maximal and, at the same, the danger of the beam passing through the tissue and reaching another area not intended, minimal.
The laser beam has to be formed and the equipment set in such a way that all the energy is absorbed within 0.5 centimeters, causing all the tissue in its way to evaporate and leading to the desired decompression. At the end of the procedure, depo steroid is injected into the intervertebral disc to avoid the pain caused by the inflammatory reaction.
The spine must be treated with care for one week following the surgical procedure with only regular mild exercising. This is to be followed by two transitional weeks, following which complete weight bearing may be resumed together with the regular work activities.
Should the procedure not be successful (current medical literature, as well as our own experience, shows the success rate at 70%), the non-surgical treatment may be continued or open surgery may be chosen.
IDET (Intradiscal Electrothermal Annuloplasty)
We first started using the IDET, the newest percutaneous procedure, in 2006.
It is a fairly new procedure used mainly in cases where sensitive proprioceptors and pressure sensors of the intervertebral disc needlessly send signals and, thereby, causing pain. It is not used when protrusion occurs on the disc wall or when a disc wall is damaged. This is checked before the surgery with a discography or a distention test.
The intervertebral disc is first punctured with a hollow 1.2 mm diameter needle from a poster lateral direction. Guided by x-ray imaging, a catheter is then passed through the needle to the intervertebral disc where the flexible catheter will be positioned to the back inner wall.
Using a preset program, the catheter tip is then slowly heated up (usually to 90 degrees Celsius). The program routinely runs for 16 1/2 minutes. As the disc gradually heats up, the patient will experience pressure that might be somewhat uncomfortable, tension in the lumbar area and, perhaps, warmth in the lower extremities. The procedure is performed with a local anesthetic with the patient awake. Following the procedure, the same instructions apply as for the percutaneous laser decompression above.
Patients with osteoporosis are prone to bone fractures. The most common among these is compression, or the collapse of a vertebra. Although the spine remains stable and does usually not require surgical intervention, it is nevertheless very painful, limiting or even impeding mobility with the symptoms lasting three to four months.
In addition, the compression causes the kyphotic (humpback) curvature of the spine to increase forcing the body to bend forward and adding to the risk of fracture which further threatens those suffering from age-related diminished bone density. When the height of the collapsed vertebra is restored, however, the kyphosis decreases, the danger of a new fracture decreases and the pain is also relieved.
In balloon kyphoplasty, two balloons are placed into the collapsed vertebra percutaneously through tiny 1 cm openings (two per vertebra). The balloons are then blown up restoring the vertebra to its original height. The balloons are then deflated and the cavity thus created is filled with liquid cement. The patient is able to get out of bed the following day, walk with an under arm support walker and, in a day or two, continue mobilization with no further aids. Minimal pain relief may be required.
Since the decision as to which vertebra was compressed earlier and fused and which is a new fracture and which is suited for this procedure is not always easy, thus, CT, MRI or isotope examination is needed. The technique may be applied from the V. dorsal to the last lumbar vertebra.
Special surgical aids
A magnifying tool used in conventional surgical techniques. Helps increase the surgeon's effectiveness through better illumination and definition and, oftentimes, makes smaller incisions possible.
The Endoscope and the Digital Camera
These are important aids in minimal invasive surgical procedures, magnifying, illuminating and allowing internal manipulation without having to resort to open surgery. It also makes lavage (flushing out with water) possible.
Our lasers are of three varying frequencies (in two units) and applied in different situations
The invisible Holmium laser with a frequency of 2100 nm, is absorbed well in water, is useful in cases involving transparent tissue and for cutting.
The Impulse laser has a capacity of 40 Watts. Is ideal for working within the intervertebral disc, the epidural area and the lumbar spine foramen with or without endoscope assistance.
The Nd-YAG or Neodynium laser with a frequency of 1064 nm is not as easily absorbed in water and allowing it to dangerously penetrate transparent tissues. We use its half strength the KTP 532 nm frequency green beam. With its 40 Watt capacity and good absorption in red tissues (i.e., hemoglobin, blood) it is useful in tumor surgery and in the resection of intervertebral tissue previously injected with contrast media.
Surgical Navigation or Computer Assisted Surgery (CAS)
Of all the surgical navigation systems, the Computer Assisted Surgery or CAS is the newest. This system allows the surgeon to follow the progress of an ongoing surgery on a previously taken X-ray, CT or MRI and precisely locate and follow the path of a surgical instrument within the patient's anatomy. This method also makes more accurate surgical procedures such as tumor removal possible and saves a patient from further x-ray exposure during surgery. Fortunately, our department has one of these most modern equipments which we routinely use daily for internal fixations with metal implants or for other interventions requiring a high level of accuracy.