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.
, 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
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