What do you do if your adult patient has chronic spine pain and scoliosis? What if your Conservative Treatment Plan is not working and your patient tells you that their condition is worsening? After reviewing your patient’s treatment options, you decide to consult a Spine Surgeon. The consultation yields two recommendations that are disappointing to your patient: 1) continue conservative treatment; and 2) at this time your patient is not a surgical candidate.
The surgical option for scoliosis can be very complex and very invasive. Highly skilled spine surgeons treating this condition carefully develop the best surgical treatment plan possible. That plan includes having sufficient reason to perform the surgery and to ensure that the benefits to the patient will far exceed the known potential risks of the planned procedure.
The more complex scoliosis cases are often managed as a staged surgical procedure. One method is to start by decompressing the nerve structures as well as remove a portion of bone, tissue and ligament in order to increase the mobility of the involved spine segments. These steps allow the surgeon to move the spine into an optimal corrective alignment. The goal of the next stage is to mobilize the spine into the optimal alignment and fixate the spine, which will allow for corrective bone fusion. Many fixation options are available which typically involve a combination use of: rods, screws, connectors, hooks, plates, grafts, cages and bone biologics.
Back to your patient; He is 70 years old, has been physically active and wants to continue to be physically active. His pain has become progressively worse over the past 12 years. His endurance to stand and ambulate has become progressively worse, especially in the past 18 months. More recently he started to use the handrail on stairs because he feels like his leg is going to give out. He also notices increased stiffness and at times provokes pain by lifting and carrying. He feels that the conservative treatments are becoming much less effective in alleviating his spine pain and states that there is no progress in increasing his mobility, strength or endurance. He refuses to use an assist device.
What changed in this patient’s spine to create these complaints? In the majority of these cases the reason for progression is unknown but often develops as the patient ages. Once the nerve structures are compressed sufficiently the patient develops neurological signs and symptoms. The history usually starts as spine pain and often advances to a variety of presentations which includes radiculopathy, claudication, decreased muscle strength or endurance.
In formulating surgical indications to treat a potential surgical candidate, the patient’s history and physical findings are used to help localize the pain source. The surgeon’s localization should correspond with what is seen on the imaging studies.
There is no clear-cut formula that clearly defines the spine mechanics and sequence of physiological changes which result in the twists and turns of the adult degenerative scoliotic spine. The alignment change is usually associated with degenerative/hypertrophic facets, degenerative disc, osteophytes, thickened/ calcified ligamentum flavum , axial vertebral body rotation and vertebral body deviation from the horizontal plane in the upright position. These changes usually cause deviations from normal lordosis and kyphosis. It is not uncommon to find that the spine has been compromised by osteomalacia or osteoporosis.
Many of the spine abnormalities can be seen and evaluated by X-ray. The X-ray shows the relationship of the vertebral bodies to one another in terms of angulation, rotation and alignment. The Spinal Canal and foramen can be further evaluated by MRI, CT , Fluoroscopy or Myelogram. Areas of concern may be further evaluated by bone scan. Other cases may involve Urodynamic testing.
So are there any other possible interventions which could help your 70 y/o patient? Is there a less extensive or less invasive intervention that could be effective? Are there some pain management options? The answer to most of these questions is usually maybe. Satisfactory outcomes vary greatly from patient to patient and success is often temporary.
One option worthy of serious consideration is Minimally Invasive Spine Surgery (MISS). This is an emerging field but what defines minimally invasive spine surgery is a work in progress. When researching various spine surgery centers throughout the country many advantages for the minimally invasive approach are advertised. The list includes: less risk, shorter recovery, lower complication rate, less blood loss, lower infection rate and the list continues. While these advantages are appealing an important point when considering a spine center is to determine the center’s experience level. That means do the surgeons perform minimally invasive procedures daily or solely or is minimally invasive surgery one of several types of surgery which the surgeons perform.
There is some consensus among surgeons that minimally invasive surgery requires a higher level of surgical skill, that the procedures demand precision in execution and that the procedures tend to use high-end technology. Many surgeons agree that those who do the most procedures can produce data which shows that their patients are exposed to lower risk, have fewer complications and have better outcomes.
One Spine Institute developed its’ minimally invasive spine surgery technique in the 1980’s and patented the system used to gain access to the spine. This center performs surgery through a tube approximately the size of a dime. No retractors or arms are required and the working tube can be used at the cervical, thoracic, lumbar or sacral spine (see Picture 1). Approximately a one-inch skin incision allows the tubes to be sequentially passed to dilate the paraspinous musculature and to dock on the spine bone surface. The dime size working tube allows passage of instruments, drills and endoscope to perform major spine surgery.
The 70 y/o patient described above had lumbar poly radiculopathy with neurogenic claudication and quadriceps weakness in the left lower extremity. His preoperative MRI (Picture 2) showed lumbar canal stenosis, foraminal stenosis and hypertrophied degenerative facets with vertebral body axial rotation and transverse angulation. This patient underwent a MISS and regained his quadriceps strength and was free of radiculopathy and claudication. He returned to being physically active (Picture 3).
John Grossmith, MD joined the surgical staff of The Bonati Spine Institute in 2007, after a long and distinguished 27-year active duty career as a medical officer in the United States Navy. A Board Certified Neurosurgeon, Dr. Grossmith served as Chairman of Neurosciences at the Naval Medical Center in San Diego, CA and as Principle Investigator for the Defense Veteran Brain Injury Center. His civilian experience includes service as an Emergency department Physician at Henry Ford Hospital and as Staff Neurosurgeon at Good Samaritan Hospital in Vincennes, IN.
Alfred Bonati, MD researched back, neck and joint pain for many years, and finding poor results and unsatisfied patients, revolutionized the field of spine surgery. Dr. Bonati created, patented and perfected minimally invasive laser spine surgery called The Bonati Spine Procedures by applying new methods and techniques including arthroscope and laser instrumentations nonexistent at that time. He continues to lead the way in the study of laser technologies to treat cervical, thoracic, and lumbar spine problems. Dr. Bonati is a strong advocate for patient rights and quality medical services. Outside of his professional duty to look after the well-being of his patients, Dr. Bonati seeks to better the lives of the members of his community through his commitment to charitable service.
For additional information about this article or the Bonati Spine Institute physicians may call (800) 330-4262; patient information is (855) 267-0482.
by John Grossmith, MD and Alfred Bonati, MD