Minimally Invasive Spinal Fusion Surgery in India - Best Spine Surgery Hospital India

Minimally Invasive SpinalFusion Surgery 

A person’s spine is subjected to a lot of forces throughout its lifetime. It may be subjected to age related wear and tear or infections like tuberculosis. As a result it undergoes degeneration which gives rise to a variety of problems like spinal osteoarthritis, disc prolapse, spondylolisthesis, osteoporotic fractures, vertebral collapse etc. All these conditions manifest as severe pain in the back and radiating pain, numbness, tingling in the upper or lower extremities (lower leg or arm) due to compression of spinal nerves,  spinal cord and spinal instability. When these symptoms become debilitating enough to preclude the patient’s day to day activity, a Spinal Fusion Surgery is advised.

What is Spinal Fusion Surgery?

The surgical procedure of spinal fusion (back fusion surgery) is performed to join one or more bony vertebrae of the spine permanently. This highly advanced procedure (disc fusion surgery) is an option for disability and pain in the spine which has been caused by some lesion and was not able to improve by other non surgical options such as medications or physiotherapy. Diseases, natural aging process and injuries are some of the causes for an unstable spine. These changes consents the abnormal movement of vertebrae and in turn the vertebrae starts to rub against each other. This can lead to either arm, back or leg pain. By fusing the vertebrae, it aligns and stabilizes the spine thereby maintaining the disc space in between the vertebrae. It saves from further damage of spinal cord and nerves.

When is Fusion Recommended

• Fracture
• Tumor
• Infection
• Spondylolisthesis
• Degenerative disc disease
• Scoliosis
• Spinal Stenosis

Types of Spinal Fusion Surgery

Lumbar spinal fusion can be divided into two categories-

Posterolateral Fusion : In the back of the spine, the bone graft is placed in amid the transverse processes. With the help of wires and screws, the vertebrae is carefully fixed throughout the particles of every vertebrae. A rod is made up of metal which is attached on the side of vertebrae.

Interbody Fusion : In this, the graft of the bone is placed in between the vertebrae and the area is generally engaged by the intervertebral disc. The disc is entirely removed in preparing for the spinal fusion. In order to maintain the disc height and spine alignment, a device can be placed in between the vertebrae. This device (intervertebral device) can either be prepared from titanium or plastic. Then the fusion starts in between the vertebrae’s endplates. Interbody fusion is of 3 types-

• Posterior Lumbar Interbody Fusion (PLIF)
• Transforaminal Lumbar Interbody Fusion (TLIF)
• Anterior Lumbar Interbody Fusion (ALIF)
• Transpsoas Interbody Fusion (XLIF or DLIF)

Posterior Lumbar Interbody Fusion (PLIF)

In Posterior lumbar interbody fusion, the spinal fusion is achieved through a surgical incision made on the posterior (back) aspect of spine. It aims at fusion of two adjacent vertebrae in cases of spinal instability and associated back pain. It is a popular procedure as it gives excellent results. The procedure provides almost complete relief of symptoms in 90-95% of the cases and the patients are able to return to their daily activities within a few weeks. The patients can also return to most of their recreational activities.

Procedure for Posterior Lumbar Interbody Fusion (PLIF)

PLIF surgery aims at achieving spinal stability through bony fusion by two ways:

The Open PLIF is the traditional technique which is performed using general anesthesia. The patient is made to lie down on his front side on the table with the low back exposed. A 3-6 inch long incision is made on the skin overlying the affected vertebrae. The skin and the fascia are cut open. The underlying muscles are retracted and the affected vertebrae are identified.  Fluoroscopic X-ray is used to confirm the exact location of the affected vertebrae. Then a complete laminectomy (removal of the lamina of the vertebrae) followed by bilateral foraminotomy (enlargement of the foramen by removing the bony spurs) and/or discectomy (removal of offending disc) are performed.

This relieves the compression off the spinal nerves, allowing them to come to their normal size and shape. The area is checked for any remaining bony outgrowth or disc fragments that may compress the nerves. Autogenic bone grafts or Metal or plastic implants are fitted in the empty disc space for initiating bone growth.

Minimally Invasive Posterior Lumbar Interbody Fusion (PLIF)

The other method is the Minimally Invasive PLIF procedure which is performed using x-ray guidance. 2.5-cm incisions are made on either side of the lower back

The muscles are gradually dilated and tubular retractors inserted to allow access to the affected area of the lumbar spine. The lamina is removed to allow visualization of the nerve roots. The offending disc material is removed from the spine and replaced with a bone graft and structural support from a cage made of bone, titanium, carbon-fiber, or a polymer, followed by placement of rod and screws. The tubular retractors are removed, allowing the dilated muscles to come back together, and the incisions are closed.

This procedure typically takes about 3 to 3 ½ hours to perform. There was less blood loss,tissue trauma, operative time, and quick recovery in this procedure as compared to the traditional one.Generally the patients can go home within 3-5 days after traditional PLIF and within 1-2 days after a minimally invasive PLIF

eXtreme lateral Interbody Fusion (XLIF)

The XLIF (eXtreme Lateral Interbody Fusion) is an approach to spinal fusion in which the surgeon accesses the intervertebral disc space and fuses the lumbar spine (low back) using a surgical approach from the side (lateral) rather than from the front (anterior) or the back (posterior).

The XLIF is one of a number of spinal fusion options that a surgeon may recommend to treat specific types of lumbar spinal disorders, such as lumbar degenerative disc disease, spondylolisthesis, scoliosis and deformity and some recurrent lumbar disc herniations and types of lumbar stenosis. It cannot be used for all types of lumbar conditions for which spinal fusion is a treatment option. For example, it cannot treat conditions at the lowest level of the spine, L5-S1 or for some people at L4-L5.

Spinal Fusion Surgery Benefits

This procedure can remove the pain as well as other symptoms. The advantages include-

• There are less chances of going through a surgery again when the level has been fused. In many cases, the facets or discs are pain producer and a fusion will make sure that the motion at the level is stopped by removing the lower back pain.
• The surgery drastically reduces the post-decompressive deformity. It has been seen that most patients have developed post-laminectomy kyphosis (abnormal alignment of the spine).
• Before the surgery, fusion can also correct the deformities of the patients so as to make sure the proper alignment of the spine is done.

Posterior Lumbar Interbody Fusion (PLIF) Surgery in India | Best Spine Hospital India

Posterior Lumbar Interbody Fusion (PLIF) Surgery in India

A posterior lumbar interbody fusion (PLIF) is a type of spine surgery that can be performed in a minimally invasive way. Posterior lumbar interbody fusion (PLIF) is a type of spine surgery that involves approaching the spine from the back (posterior) of the body to place bone graft material between two adjacent vertebrae (interbody) to promote bone growth that joins together, or "fuses," the two structures (fusion). The bone graft material acts as a bridge, or scaffold, on which new bone can grow. The ultimate goal of the procedure is to restore spinal stability.

Today, a PLIF may be performed using minimally invasive spine surgery, which allows the surgeon to use small incisions and gently separate the muscles surrounding the spine rather than cutting them. Traditional, open spine surgery involves cutting or stripping the muscles from the spine. A minimally invasive approach preserves the surrounding muscular and vascular function, minimizes scarring, hastens recovery and decreases hospitalization stay.

How is it done?

PLIF surgery aims at achieving spinal stability through bony fusion by two ways: The Open PLIF is the traditional technique which is performed using general anesthesia. The patient is made to lie down on his front side on the table with the low back exposed. A 3-6 inch long incision is made on the skin overlying the affected vertebrae. The skin and the fascia are cut open. The underlying muscles are retracted and the affected vertebrae are identified. Fluoroscopic X-ray is used to confirm the exact location of the affected vertebrae. Then a complete laminectomy (removal of the lamina of the vertebrae) followed by bilateral foraminotomy (enlargement of the foramen by removing the bony spurs) and/or discectomy (removal of offending disc) are performed.

This relieves the compression off the spinal nerves, allowing them to come to their normal size and shape. The area is checked for any remaining bony outgrowth or disc fragments that may compress the nerves. Autogenic bone grafts or Metal or plastic implants are fitted in the empty disc space for initiating bone growth. Finally, pedicle screws are placed into the upper and lower vertebrae and connected with rods or plates. New bone is allowed to grow over these rods, helping to bridge the adjacent vertebrae and achieving interbody fusion. The total surgery time is approximately 3 to 6 hours, depending on the number of spinal levels involved.

The other method is the Minimally Invasive PLIF procedure which is performed using x-ray guidance: 2.5-cm incisions are made on either side of the lower back. The muscles are gradually dilated and tubular retractors inserted to allow access to the affected area of the lumbar spine. The lamina is removed to allow visualization of the nerve roots. The offending disc material is removed from the spine and replaced with a bone graft and structural support from a cage made of bone, titanium, carbon-fiber, or a polymer, followed by placement of rod and screws. The tubular retractors are removed, allowing the dilated muscles to come back together, and the incisions are closed. This procedure typically takes about 3 to 3 ½ hours to perform. There was less blood loss, tissue trauma, operative time, and quick recovery in this procedure as compared to the traditional one

Post-Operative Care after PLIF

Most patients are usually able to go home 3-5 days after surgery. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury. Patients can gradually begin to bend, twist, and lift after 4-6 weeks as the pain subsides and the back muscles get stronger.

Recovery from PLIF

Rehabilitation after PLIF can be a slow process. Many surgeons prescribe outpatient physical therapy beginning a minimum of six weeks after surgery. This delay is needed to make sure the graft has time to begin to fuse. You will probably need to attend therapy sessions for two to three months. You should expect full recovery to take up to eight months.

Cervical Disc Replacement Surgery in India | Best Spine Surgery Hospital India

Cervical Disc Replacement Surgery in India

This promising new procedure is a boon for all those suffering from severe and intractable neck pain. It has revolutionized the approach used for treating patients with severe longstanding cervical spondylitis, whiplash injuries, cervical disc prolapse, offering them a better quality of life. Also known as artificial disc replacement, this technique is fast becoming popular amidst surgeons and patients alike because of its excellent results. It is considered superior to cervical spine fusion surgeries as it maintains normal neck motion post operatively and ensures early return of patient to normal activities. In this procedure a stainless steel disc with a ball in trough design is inserted between the affected cervical vertebrae. This helps to simulate natural neck movements. The patient stays in the hospital for 1-2 days and resumes work in 45 days.

Working Anatomy of Cervical Spine

The cervical spine consists of 7 cervical vertebrae named C1, C2, C3, C4, C5, C6, C7 with shock absorbing intervertebral disc in between them. These discs allow for the smooth rotating and bending movements of the cervical spine. With age these discs lose their water content and get compressed between the vertebrae which may lead to herniation of disc contents. Along with this there is wear and tear of the vertebrae causing formation bony outgrowths known as (osteophytes). The prolapsed disc can compress the spinal cord within the spinal canal (myelopathy) or the exiting nerve roots at the intervertebral foramina (lateral openings between each vertebral pair) causing radiculopathy (radiating pain in the arm).

Objective of the Procedure

The cervical segments C4- C5, C5-C6, C6-C7 are more vulnerable to disc prolapse and spondylitis due greater mobility at these joints. Disc prolapse results in reduction of intervertebral distance which causes pressure on the exiting nerve roots at intervertebral foramina. Disc replacement surgery aims at reducing the symptoms of degenerative joint disease. Replacing the damaged disc with an artificial implant or prosthesis, restores the normal distance between the two vertebrae and relieves the pressure on the nerve roots.

Why is Cervical Disc Replacement Surgery required?

A large number of people nowadays face neck, shoulder and/ or pain in the arms mainly because of the abnormalities in the neck. These complaints can be signs of disc herniations or disc degeneration, and/or arthritis of the neck.

The cervical spine is composed of vertebral bodies and intervertebral discs. These discs wear out with time causing pain and other symptoms and are referred to as degenerative disc disease, a subgroup of which includes cervical disc herniations. This means the disc becomes compressed, frayed, and/or herniates into the adjacent spinal canal where it can press on nerves or the spinal cord.

Most patients with these types of symptoms do not need surgery and improve with conservative like anti-inflammatory medications, physical therapy, or cold/heat therapy. However, if a person continues to have significant neck pain and/or radicular arm pain, he or she may be a candidate for cervical spine surgery. An anterior discectomy and fusion is the most common operation for treating patients with symptoms related to a degenerative or herniated disc in the neck.

Cervical Disc Replacement Surgery- The Procedure

The procedure for cervical disc replacement surgery consists of removing the problem disc entirely and replacing it with a piece of bone taken either from the patient's hip and a metal plate with screws and/or a cervical collar may also be used to help hold the bone in place and to allow this segment of the neck to fuse together. The purpose of an anterior cervical discectomy and fusion surgery is twofold:

• To remove the offending agent—either the herniated disc or the osteophytes that are compressing the nerves and/or spinal cord.
• To eliminate motion by inducing a fusion at the disc space where the disc has been removed, aided by the use of bone grafts and possibly plates/screws, etc. and thereby creating stability and/or eliminating pain associated with the motion.

This type of surgery typically improves the pain in over 90% of people with one-level disease. However, there may be complications in using bone grafts in pursuit of a fusion. Harvest of one's own bone may be associated with both acute and potentially long-term pain from the donor site. Any type of bone graft may fail to heal, resulting in a so-called 'non-union', which may require another fusion operation.

Also, by fusing a segment of the spine, the levels of the spine above and below the fused area are now forced to absorb more load since there is no longer any intervening motion shock absorption. These adjacent levels will then wear out and become symptomatic in more than 25% of these patients within ten years, meaning possibly more surgery. This is called adjacent-segment degeneration.

The development of artificial cervical discs is intended to accomplish the same objectives as the traditional decompression and fusion surgery in terms of providing pain relief and stability, but with fewer drawbacks. For example, the cervical artificial disc does not include the potential complications involved with using bone graft (e.g. 'non-unions') and theoretically should lessen the risk of developing adjacent-segment disc degeneration or disease.

Post operative Recovery and Rehabilitation Period

The patient stays in the hospital for 1-2 days and resumes work in 45 days post operatively. Avoid bending neck backwards. A brace or soft collar may be recommended after the operation to support the neck muscles. Physical therapy may be prescribed 1-2 weeks after surgery which has to be done on outpatient basis. The therapy will initially start with pain relieving modalities such as ice, electrical stimulation to reduce pain followed by gentle active exercises. Gradually gentle stretching, strengthening and endurance exercises to the neck muscles are introduced. The therapist gives instructions on how to maintain the neck postures during various tasks of daily living. This is followed by a home exercise program.