More involved spinal surgery usually involves a bit more time, and usually requires one night in the hospital. This type of spinal surgery generally involves some type of spinal instrumentation and fusion. The most common type is a lumbar fusion. This type of surgery is usually performed for any condition that might cause spinal instability, whether from the primary disease or from the surgical approach. The artificial disc is sometimes an option in the cervical spine, but is not often utilized in the lumbar spine, owing to different biomechanics.
More involved spinal surgery is generally indicated for the patients that have extremity pain, and it is felt that either the condition itself is causing the leg pain (i.e.formanial stenosis, spondylolithesis), or that the surgery required to relieve the nerve root compression would destabilize the spine. As with all surgery, it is generally used as a last resort when the patient has failed all conservative treatment options, with the notable exception of a neurologic deficit or impending neurologic deficit. Some common procedures we perform include:
All the lumbar fusions we perform are minimally invasive. We do not perform any open posterior fusions. All lumbar fusion involve removal of the disc and spinal re-alignment through an XLIF or ALIF approach, followed by minimally invasive posterior fusion (usually with percutaneous pedicle screws, but occasionally other devices). If a decompression is needed, this is also done in a nimbly invasive fusion. Minimally invasive surgery is not always after that traditional surgery, but results in better outcomes, less complications, and high patient satisfaction. We have several years of data to support this statement.
The most common indication for a lumbar fusion include:
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Spondylolithesis: This is one of the more common conditions that may cause back and leg pain and may require surgery. There are essentially two types. An isthmic type is due to a defect in part of the spine, it usually occurs in younger patients and at the L5-S1 level. The second is an arthritic or degenerative type, which usually occurs in older patients and at L4-5 or above. This makes up the majority of our spinal fusion practice, and has the better medical support for the effectiveness of surgery (compared to other degenerative spinal conditions).
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Adjacent Segment disease: This is when a level above or below a previous fusion wear out faster than normal, as a result of the extra work these segments have had to do.
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Myelopathy: This is when the spinal cord is being compressed and caused sign and symptoms. This is potentially a very serious condition and often requires surgery. Intraoperative monitoring is usually performed (when cord compression is present) to confirm the integrity of the spinal pathways during surgery
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Kyphosis: This is a condition where the spine is bent abnormally forward, and can cause severe pain, and more serious problems such as spinal cord compression/myelopathy.
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Post laminectomy Syndrome: This can occur in the neck or back, and may result in scar tissue, deformity, and chronic pain
Revision surgery: This includes patients with re-herniated pics, segmental instability, and those that have undergone a fusion procedure but did not fuse (pseudoarthrosis)
Miscellaneous causes: There are a variety of other conditions that may require a fusion, such as removal of spinal tumors, misalignment of the spine, segmental instability, and painful disc disease (where the pain generator is felt to be in the disc). Fusion is rarely recommended for so called degenerative disc disease, as the results are simply not as consistent as for other less controversial causes.
Surgeries we commonly perform
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XLIF: This is a minimally invasive lumbar fusion of the anterior column of the spine, like an ALIF (see below), but performed through a small opening in the side / flank. This is the procedure that has truly revolutionized minimally invasive spine surgery, and there are several hundred papers now published on the XLIF procedure, as well as our own publications, showing the benefits of this operation compared to traditional open posterior fusions.
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ALIF: Anterior lumbar interbody fusion. An XLIF can be performed at every level in the lumbar spine except L5-S1. At this level, we perform the ALIF procedure, which accomplished the same goal, but the incision in on the lower abdomen. This procedure is most often performed with the patient on their side, so we have access to the back to place minimally invasive instrumentation.
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Percutaneous Pedicle screws: This is often performed after an ALIF and/or XLIF has been performed, to maintain the alignment of the spine. Because the fusion is done through the front of the spine, these screws can be place through small, 10-15mm incisions.
