New Advances in Spinal Surgery

Stephen Robbins, M.D., orthopedic surgeon affiliated with Columbia St. Mary’s

Last Updated: Sept. 1, 2003

Advances in diagnostic techniques coupled with state-of-the-art instrumentation and materials have created a host of new procedures, and dramatic improvements to familiar ones, for treating serious spinal problems.

These include microdiscectomy for lumbar herniated disks, spinal fusion with the use of cages for degenerative disks, and a recently approved procedure called kyphoplasty for treating osteoporotic fractures. In addition within six months the FDA is expected to approve artificial disk replacement.

Stephen Robbins, M.D., Orthopedic Surgeon affiliated with Columbia St. Mary's "Choosing a surgeon often depends on the kind of expertise in your community. If you are in a situation where you have a wealth of doctors specializing in spinal surgery, I would choose those individuals first because they have dedicated their lives to a specific diagnosis and have better expertise."

However, it should be stressed that spinal surgery is usually the last resort, undertaken after more conservative treatment has been tried.

“Most of the time the conservative measures work. When they don’t, and a patient is still in significant pain, it is time to see a spinal surgeon for an evaluation,” said Dr. Stephen Robbins, an orthopedic surgeon with Columbia St. Mary’s.

Microdiscectomy
Microdiscectomy is used for treating lumbar herniated disks when the herniated disks may place pressure on spinal nerves. The pressure may cause lower back pain, or more likely pain, numbness and weakness in the legs which can be severe.

In microdiscectomy, a portion of the disk that is putting pressure on the nerve is removed. The extra space allows the nerve to heal. And while it may take weeks for this to occur, many patients feel better almost immediately.

“Typically, the best patients for this type of surgery are those in their twenties and thirties with an isolated disk herniation and acute pain. For them, this surgery will usually have an excellent outcome,” Dr. Robbins said.

Spinal fusion
Degenerative disk disease may cause severe pain when a disk wears out. When other measures have been tried and failed, the best relief may come with a spinal fusion. In this procedure, two vertebrae are linked so that they cannot move. The fusion stops the motion, which stops the pain.

In general, spinal fusion has the best results when used in the lumbar area, or lower back, for a single segment. In this case, most patients will not notice any stiffness from loss of motion in the spine.

In the past this has been done with a bone bridge, usually harvested from the hip. Donated bone also can be used, though the fusion is not as good. The harvesting of bone does increase operating time and adds pain at the bone graft site.

Recently, two new techniques have made fusions more effective and shortened recovery time. These include the use of cages and a special substance called BMP (bone morphogenetic protein).

Cages are titanium cylinders that are placed through the disk space holding the vertebrae together. They are porous so that in time the patient’s own bone will grow through them, acting as cement to hold fused vertebrae in place.

BMP is then injected into the cages, replacing the need for a bone graft. This naturally occurring substance stimulates bone growth, speeds recovery time and improves fusion rates.

“Today’s fusions use smaller incisions, so there is less risk to the patient and less trauma to the muscles,” Dr. Robbins said.

Today, a one level spinal fusion has about a 90% success rate, two level fusions about 80%. They can sometimes be done as outpatient surgery or with a one-night hospital stay.

Kyphoplasty
Osteoporosis can affect any of the bones in the body. When it affects the spine, it can cause the vertebrae to weaken and collapse forward. This is the source of the “dowagers hump” or shortened stature in older adults.

The collapse also can cause a host of problems ranging from chronic or severe pain to decreased lung capacity. And, the first fracture makes it far more likely that additional fractures will occur.

Standard treatment for this type of fracture has been the use of a brace and medications. With kyphoplasty, a tiny balloon is guided into place and slowly inflated to restore the bone pieces to a more normal position. Cement then freezes them into a correct alignment to correct the spinal deformity as well as the fracture.

“This is a good option for older patients as well as for some patients with cancer affecting the bone,” Dr. Robbins said.

The surgery can be done with either a local or general anesthetic. A one-night hospital stay is usually involved. The patients usually have complete relief of their pain.

Coming soon – artificial disk replacement
The artificial disk is expected to be approved by the FDA (Federal Drug Administration) in the next few months. With it, surgeons will be able to replace a damaged disk with an artificial one. Already being used in Europe, it has a high success rate and is able to preserve flexibility in the spine. “The procedure is very similar to fusion, so it should be widespread soon after FDA release. It will likely be used first in the lumbar area, later in the cervical area,” Dr. Robbins said.

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