No more are the days where a large incision is used to "explore the spine." Exploration should be left to spelunkers and astronauts - not spine surgeons.
About 30 years ago, you would hear these refrains: "Never get back surgery as you'll never be the same." "I don't know anyone who has improved from spine surgery." "All my friends who have had back surgery are worse off now."
Time, knowledge and techniques have changed dramatically since the old days. The current success rate for surgery should be up to 95 percent. There is a phenomenally greater understanding of spinal pathology and surgical indications. The technical ability of surgeons has improved dramatically and the professional tools of the trade are significantly better. The ability to diagnose disorders has been enhanced since the advent of the MRI and higher-powered CT scanners. Surgical implants have been refined and there's greater knowledge about the biochemistry of healing.
One of the advancements has been in the surgical approach to the spine. Back when dinosaurs walked the earth, I can remember the surgical phrase, "Incisions heal side to side." The idea taught years ago was that it did not matter how long the incision was, as all incisions would eventually heal "side to side."
That thought pattern has thankfully fallen off the cliff. Incisions to access the spine are not always benign. Muscle has to be moved or removed and ligaments may need to be ligated and then reattached to gain access to the spine. There are now minimally-invasive techniques to allow spine surgery with minimum tissue invasion.
The smaller incisions now allow windows or "portholes" for spinal access. Through a small incision (normally about 20 millimeters), herniated discs can be removed, bones spurs that compress nerves can be ablated and a narrowed spinal canal can be enlarged. This precision has come about because the newer scans allow better knowledge of the pathology. The surgical plan should be so accurate that there are no surprises.
Minimally invasive means minimal tissue disruption for the surgical approach. This technique reduces post-operative pain and speeds rehabilitation. There are many ways to reach these goals. At Vail Valley Medical Center, we have a state-of-the-art intraoperative CT scanner called the "O Arm" and a device called a "stealth station" that allows us to image the spine in three dimensions while the patient is asleep. These devices allow us to be very accurate with how we place implants and we can reduce the incision size by at least half. For certain approaches to the spine, small tube retractors can be placed to reduce the retraction of muscles.
Along with minimally-invasive techniques are new technologies for motion preservation and fusion. There are now artificial discs that can allow motion in areas that could only previously be fused. These artificial discs work well in the neck in selected patients but are still not perfected for the lower back. Bone morphogenic protein is a recently developed synthetic human protein that causes indigenous stem cells to turn into bone cells. Using this material in surgery has allowed for greater surgical sucess and a quicker recovery for patients requiring fusion.
With all the recent developments in spinal surgery, all in all, spine surgery has never been so safe, successful and satisfactory.
Dr. Donald Corenman is an orthopedic spine specialist, surgeon and researcher practicing at The Steadman Clinic in Vail. His spine education website, neckandback.com, and online video series, youtube.com/neckandback, have become a popular resource for people with neck and back pain. To learn more about the techniques discused in this article see the two surgical videos that demonstrate "posterior cervical foramenotomy" and "the O arm."
