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Spine Surgery

Important Advances

in Spine Surgery

The last few years have seen an enormous focus on management and

surgical treatment of low back pain.This is an area of great socioeconomic

importance in all age groups throughout the world. Sophisticated new

techniques have necessitated dedicated specialisation in the area of back

surgery.There is no doubt that surgery has an important, established place

for the treatment of back pain.

Though microsurgical discectomy remains a potent tool to treat sciatica, it can be

used with success where a lumbar disc has herniated and compressed a nerve root.

However, microdiscectomy/discectomy, is an unreliable operation for the management

of back pain.This single fact leads to misunderstanding and frustration.

Low back pain often, but not inevitably, occurs alongside, and is a consequence of,

degeneration of the principal load-bearing component of the spine; firstly, the disc and

subsequently, the associated facet joint.The discs sit in-between the vertebral bodies

and a whole family of interbody strategies has evolved, of which the Interbody Fusion

(IF) remains the gold-standard.The Posterior Lumbar Interbody Fusion (PLIF) retains

its position as the work-horse in this category, along with its anterior transforaminal

and extreme lateral (ALIF,TLIF and XLIF) siblings.

Accessing and fusing the interbody space reliably is technically challenging, requiring

a load-bearing device filled with bone graft to fill the gap created after the removal

of the disc. Some surgeons, understandably, prefer to stiffen the motion segment,

of which the disc is the major component, with metalwork made to attach to the

vertebrae lying either side. But these are far less effective when used alone without

addressing the interbody space.

Although arthroplasty surgery (disc replacement) has been around for decades, it has

not had widespread acceptance for various reasons.Among these is the fact that disc

replacements are almost universally inserted from the front/anterior, which involves

mobilising the major blood vessels (aorta and vena cava) in the body. In addition, disc

replacements do not address facet joint arthropathy (wear and tear), which in itself is

a potent cause of pain.

The major emphasis in the last few years has been on improving the reliability of

surgery and decreasing its magnitude or invasiveness.These goals have been difficult

to reconcile, but progress has been achieved. Bone Morphogenic Proteins (BMP) in

recombinant form have become available and demonstrated their efficacy in bone

healing, whilst novel tools allowing real-time intra-operative monitoring of nerves has

increased certainty and allowed operations to be undertaken safely through small

incisions.A prime example of where these advances have met has been the Extreme

Lateral Interbody Fusion (XLIF) procedure.

The operation is undertaken typically through a 5cm incision with the patient on

their side.A sophisticated retraction device is positioned through the incision, the

orientation and position of the nerve root having already been established using nerve

monitoring (see below). Following discectomy and vertebral endplate preparation,

the device is placed both under direct vision and using intra-operative fluoroscopy to

ensure accurate placement.Astonishingly, blood loss may typically be 10 to 20mls.

For the growing elderly population particularly, these techniques, combined with other

less invasive approaches, provide powerful strategies.

It would be foolhardy to say that a final solution has been reached for all the complex

problems that fit under the outwardly mundane and unappealing heading of low back

pain. It would be equally foolhardy to deny the significant efforts, energy and progress

that continue to be poured into this fascinating and important area.

Fig 1. shows a Nerve Monitoring Station. Fig 2. shows a surgeon checking with the nerve

monitoring device, and Fig 3. shows discectomy and fusion with retractor in place.

For further information, please contact Mr Bhupal Chitnavis’ secretary on

020 7357 0494


Fig 2a and 2b.

The SynFrame


, a frame-based

retractor system, allowing mini-open

surgical incisions. This example shows

a minimal access approach to the

thoraco-lumbar spine to treat a spinal


Specialised specialists

Only surgeons competent in MASS

should perform these techniques because

catastrophic complications can occur from

injury to the abdominal viscera, blood

vessels and neurological structures.

An aspiring spinal surgeon must be able to

master the conventional open technique

before embarking on MASS techniques.

Akin to MISS, MASS also has a relatively

steep learning curve and the potential

for complications remains identical to

that of conventional open approaches. In

addition to the need to possess inherent

three-dimensional spacial awareness, the

surgeon must undergo mandatory training

and certification in order to master the

hand-eye co-ordination tasks required. As

indicated, meticulous planning and thorough

knowledge of the surgical anatomy and

equipment is essential for achieving success

in MASS. In carefully selected patients, a

more experienced surgeon will realise and

appreciate the intricacies of a well executed

MASS, often being rewarded by patients

who will enjoy a marked reduction in

approach-related post-operative pain,

hospital stay and post-operative


For further information, please

contact Mr Khai Lam’s secretary on

020 7403 4516