Spinal Surgery
Spinal and Brain Tumors
Minimally Invasive Spine
Surgery
What Is Minimally Invasive Spine Surgery?
In essence,
minimally invasive spine surgery is the performance of surgery through
small incision, usually with the aid of microscopes or endoscopic
visualization (i.e., very small devices or cameras designed for
viewing internal portions of the body).
Why Is Minimally Invasive Spine Surgery Needed?
Minimally invasive
spine surgery has developed out of the desire to effectively treat
disorders of the spinal discs with minimal muscle related injury, and
with rapid recovery.
Traditionally,
surgical approaches to the spine have necessitated prolonged recovery
time. For example, prior to the use of the operating room microscope a
large incision was used to visualize the herniated lumbar disc. In
order to perform this procedure, large sections of the back muscles
are moved away from their spinal attachments.
First, this
surgical approach (i.e., dissecting the muscles) produces the majority
of the perioperative pain and delays return to full activity. The
degree of the perioperative pain necessitates the use of significant
pain medication with their inherent side effects. Also, the degree of
the perioperative pain delays return to normal daily activities and
nonphysical work.
Second, the
dissection of the paraspinal muscles from their normal anatomic points
of attachment results in a healing by scarring of these muscles. The
various layers of the individual muscle scar to one another losing
their independent function.
In addition, it has
been found that this type of dissection sometimes results in the loss
of innervation (i.e., the supply of nerve stimulation) of the muscles
with subsequent wasting away. A permanent weakness of the back muscles
results. This weakness itself may be symptomatic (as a back
fatigue-type pain) and/or limit the patient's function - particularly
in those who perform physical work.
Clearly, with such
significant muscle injury associated with surgical approaches to the
spine, the need existed for the development of less invasive surgical
techniques. It was envisioned that minimally invasive techniques would
offer several advantages including: -Reduced surgical complications -
Reduced surgical blood loss - Reduced use of post-op narcotic pain
medicines - Reduced length of hospital stay - Increased speed of
functional return to daily activities
History of
Minimally Invasive Disc Surgery
In
1964—Lyman Smith, an orthopedic surgeon in Chicago, was the first to
inject, percutaneously, chymopapain into a patient with sciatica with
the purpose of hydrolyzing the mucoprotein of the herniated nucleus
pulposus.
In 1975 Hijikata performed a percutaneous nucleotomy by
inserting a 7-mm diameter tube down to the annulus fibrosis and, then,
using specially designed forceps removed disc material.
In 1977-78 Yasargil,
Caspar and Williams pioneered the use of the operating microscope and
microsurgical techniques for treating lumbar disc disease.
In 1983 Kambin began developing what eventually would
be a modified arthroscopic approach to lumbar discectomy using a
working sheath with a 6.5 mm outer diameter and coring instruments and
forceps designed for a 5 mm inner access.
Onik and subsequently Maroon and Onik described and
published their early results with automated percutaneous discectomy
using a guillotine like 2 mm probe inserted fluoroscopically into the
disc space.
In 1987 Choy and Asher described laser
discectomy and subsequently laser energy has been used percutaneously
for disc ablation.
In 1993 Mayer and Brock discussed the
use of the endoscope for percutaneous discectomy. Subsequently Smith
and Foley designed instrumentation and endoscopic equipment to perform
a micro-endoscopic approach to lumbar disc removal.
In 2000, intradiscal electrothermal
energy as well as newly designed lasers are being advocated for
percutaneous thermal annuloplasty in patients with low back pain.
Summary of Microscopic Approach
In 1965-66 Gazi Yasargil spent 14 months
with R. Peardon Donaghy at the University of Vermont developing the
microsurgical instrumentation and techniques that would revolutionize
the surgical approach to many neurosurgical diseases. Upon returning
to Zurich 1n 1967, he applied his knowledge and microsurgical skills
to reduce the morbidity and improve the outcome in patients with
aneurysms, arteriovenous malformations, various neoplasms—and
herniated lumbar discs.
The
first publication of the microsurgical discectomy procedure was in
1977 in the journal, Advances in Neurosurgery. It was
Williams, a Las Vegas neurosurgeon and consultant to many of the
casinos employing female dancers, that popularized the technique in
the United States. He supported his hypothesis that surgical scars
could be minimized and performers could return to dancing quicker
through techniques he described in his 532 reported patients.
Subsequently Goald and Ebeling, et al, Wilson and Harbaugh, and Maroon
and many others have confirmed the ability to reduce incision size,
blood loss and morbidity with the microsurgical technique. Success
rates of microdiscectomy range from 88% to 98.5% in various series.
Because of the
small incision, the diminished trauma to lumbar musculature, the
easier identification of deep seated structures, the minimal traumatic
manipulation of neural structures and the direct view into the disc
with magnification and coaxial illumination, for the most part, this
resistance has faded and the great majority of neurosurgeons now use
magnification if not the operating microscope in performing lumbar
disc surgery.
Our surgical
approach is similar, with a few modifications, to that described by
Yasargil, Caspar and Williams. Patients are placed in the lateral
decubitus position, slightly flexed with the affected side up and the
surgeon is seated. X-ray is used to confirm the correct interspace.
Prophylactic intravenous antibiotics are given in one dose at least 30
minutes prior to the skin incision. A 15-25 mm skin incision is made.
The operating
microscope with a 300-mm objective is then brought into use. A low
profile, high speed drill is used to drill a small window in the
bone. Free fragments and attached disc material are removed and
pressure is released from the nerve root. And the bony opening which
the nerve pasts is also enlarged. Steri strips and a band-aid are
applied to the wound.
Patients are
urged to ambulate immediately and are discharged within 23 hours,
either the same day or the following morning in 95% of the cases. Our
results have not significantly changed since our earlier report. The
average operating time is less than one hour. Approximately 90% of
patients obtain good to excellent pain relief. Complications such as
dural tears, nerve root injury and discitis are under 1.5%. Long term
reoperations at the same level are under 5%. No transfusions, great
vessel or retroperitoneal injuries or mortality has occurred in over
2,500 operations.
Conclusion
and Comparisons
When one compares
the surgical outcome and overall experience with microsurgical
discectomy with percutaneous techniques such as chemonucleolysis,
automated percutaneous lumbar discectomy, modified nucleotomy and
transforaminal endoscopic techniques the microsurgical approach
appears to be superior in most areas. Obviously, laser discectomy has
no place with extruded or sequestered fragments and none of the other
techniques deal with lateral recess or foraminal stenosis, hypertrophy
of the ligamentum flavum or osteophytes that occasionally are
encountered unawares.
A valid
comparison can be drawn between the micro-endoscopic technique and the
strict microsurgical method. Proponents of MED assert that the
primary differences with the microsurgical approach are 1) a smaller
skin incision, 2) a muscle splitting rather than a subperiosteal
approach to the lamina, 3) less postoperative pain, 4) faster hospital
discharge and 5) a quicker return to employment. Once exposure
through the tubular endoscopic system is obtained, the endoscopic
technique for ligamentum flavum removal, discectomy and foraminotomy
are the same as that used in the microsurgical approach.
With the
microsurgical approach described above virtually the same size
surgical incision is made, 15-20 mm, and the same surgical technique
is used for discectomy. The primary difference, therefore, is a
subperiosteal dissection versus a muscle splitting dissection which,
in our opinion, is minor. Many surgeons have demonstrated the incision
size, hospital stay and results are at least equivalent to that
reported with the MED system. The return to work interval is also
comparable.
Dr. El Kadi and
his Associates have spent the last 25 years investigating and
reporting on minimally invasive approaches to the lumbar disc. They
believe there still are indications for APLD, disc ablation with
lasers, endoscopic techniques and nucleotomy in very carefully
selected patients. Despite the relative ease of performance in some
cases, however, none of these methods have found their place in the
hands of the majority of surgeons due either to the paucity of long
term results, the potential and real complication rate or the learning
curve in acquiring the technical skills. With the tremendous advances
in neuro imaging, better understanding of the pathophysiology of disc
disease and the innovations in technological development, pursuit of
unique and minimally invasive ways to treat lumbar disc disease must
continue. Nevertheless, microsurgical discectomy remains the
procedure of choice for the majority of patients requiring surgery and
continues to be the standard against which all other procedures must
be measured.
Call, toll-free, at 412-630-7640 or 877-635-5234 to learn more.
Microdiscectomy: Patient
Education
Index:
Basic Information
Why you
are here?
Most likely, the pain in your back or
legs, or both, ultimately led you to seek help. You have been
diagnosed as having a herniated lumbar disk and require lumbar
microdiscectomy. Disks are the shock-absorbing cushions between the
lumbar vertebrae of your spinal column. These disks can herniate for a
variety of reasons, including age, stress, strain and sudden impact.
Herniation of the
disk, as pictured above, results in the soft inner contents of
the disk pushing through the fibrous outer wall and pressing, against
the nerves that run parallel to the spinal column. Even slight
movement can cause the nerve to be irritated and thus cause pain,
numbness and weakness in the leg and foot. The lumbar microdiscectomy
procedure is designed to remove this herniated material from the
nerves and relieve your symptoms.
Information For a Patient Referred of a Office
Evaluation
You have been referred to a
neurosurgeon for an evaluation that may result in having a surgical
procedure called microdiscectomy. Microdiscectomy generally is
performed to correct a herniated disk. Most likely, you will
return to the many activities you enjoyed before your back problems
occurred. If your evaluation indicates you are a candidate for this
surgery, the steps below will serve as a general guideline from your
first office visit to your return home.
Your first office visit
· Please remember to bring your
insurance information and a completed medical history form. You
should have received this form by mail or at the time of your visit.
This medical history form provides information about your current and
past medical history, along with any prior anesthesia complications,
your current medications and any drug allergies.
· Please bring the results of any
prior diagnostic test related to your condition. Also bring the actual
X-ray pictures from any computed tomography (CT) scan, magnetic
resonance imaging (MRI) scan, myelogram, plain X-rays or other test
that was done to evaluate your back problem.
Your examination
Your neurosurgeon and his staff will
interview you in the examination room. This will include a review of
the medical history form you have completed and questions about your
back problem. A comprehensive neurological and physical exam will be
performed, and any diagnostic tests and X-rays, will be reviewed.
Results of this exam may indicate the need for further-diagnostic
tests, conservative therapies or possible, surgical recommendation.
If Surgery is Required
· You may need to do several things
to ensure that your insurance company has approved, the operation
scheduled for you. Many insurance companies require
pre-certification and second opinions. It is your responsibility
to ask your insurance company about its particular requirements.
· If you have a pre-existing medical
condition and are under a doctor's care, you will receive a
consultation clearance form to be completed by your doctor. This
should be faxed by your doctor to your neurosurgeon's office as soon
possible, so surgery is not delayed. Also, plan to bring a copy of
this form to the hospital's Same Day Surgery Unit on the day of your
surgery.
Same Day Surgery
Fax: 412-692-2955
Phone: 412-692-2222
Testing before your Surgery
· On the day of your office visit,
you will receive a prescription for pre-surgical testing to detect any
blood abnormalities. These tests can be done up to 14 days prior to
your surgery date. The results must be reviewed by the neurosurgeon's
office no later than two working days before your surgery date. The
prescription allows any certified laboratory approved by your
insurance company, to do the blood and urine tests and forward
the results to the neurosurgeon's office for review.
· Chest X-ray and EKG may need to be
done at your local hospital or doctor's office because some labs do
not have these capabilities.
Pre-admission packet
· A pre-admission packet will
be given to you by the neurosurgeon's office on the day of your visit
or mailed to you if surgery is required.
Included in the packet is general information about the Hospital and
its procedures. Please read all of the pre-admission materials
completely. This brochure does not cover all the steps you'll need to
take on the day of your surgery.
Please read all
hospital-related materials.
Microdiscectomy: A Patient's Guide to Surgery
You have been referred for a
procedure called lumbar microdiscectomy.
Our goal is to return you to optimum
health following surgery and send you home the day after
your operation.
following surgery and
send you home the day after
your operation.
The following information should help
you understand what will be involved with the surgery. This guide is
not intended to take the place of the neurosurgical team's
explanation, but is designed to answer some common questions and make
you familiar with common terms and procedures related to lumbar
microdiscectomy surgery.
Testing and therapy before Surgery:
Our goal is to return you to your
activities prior to herniating your disk. Conservative therapy or
non-surgical treatment is often used before surgery. Occasionally,
conservative therapy may relieve the symptoms associated with a
herniated disk and eliminate the need for surgery. Because
conservative therapies such as bed rest, medications and physical
therapy have not been effective for you, your neurosurgeon has
recommend lumbar microdiscectomy.
Diagnostic tests such as lumbar
computed tomography (CT), magnetic resonance imaging (MRI) and
myelograms indicate the level degree of herniation and allow your
neurosurgeon to precisely perform the procedure. One or more of these
tests may be necessary to accurately diagnose the problem.
The Procedure and its Benefits:
Microdiscectomy takes about one to
two hours to perform. Your incision will be about 1 to 2 inches long
on the mid-low back area. Generally, you will be walking the day of
surgery and can be discharged the day after your operation. Please
arrange your transportation home in advance.
The risks involved with this type of
surgery are: Infection, excess bleeding, no relief of symptoms, excess
scarring, increased neurological dysfunction, anesthetic
complications, and/or death.
After surgery, minor discomfort from
your incision is common but temporary. This can be relieved with mild
pain medication. Following the procedure, you may experience
persistent numbness, weakness and pain along the path of the nerve
that was decompressed, but these symptoms are generally temporary and
gradually go away.
Discharge instructions will be
provided to you in a informational packet and review
with you prior to discharge.. Your activities will be limited until
you come for your postoperative follow-up visit.
Members of the health-care team:
You will meet a number of
health professionals during this time. Their goal is to help you
recover and return you to your prior activities. A brief description
of each of these professionals follows:
Neurosurgeon.
You have already met this person, who will perform the
surgery and direct your care afterward. Please feel comfortable asking
questions of your surgeon -
communication is an essential key toward
recovery.
Nurse.
A nurse will assess your condition both in the surgeon's office
and in the hospital. The office nurse will evaluate you before you see
the surgeon and again with the surgeon at the time of your visit. The
office nurse will help explain the procedure, answer questions and
arrange your surgery. The hospital nurse will assess you in the
hospital, and help you before, during and after your surgery. The
nurse also will answer questions from you and your family.
Physician assistant.-
The physician assistant (PA) has -been trained to perform many
tasks done by a physician. The PA may perform your history and
physical examination and review the surgical procedure. The PA can
answer questions and will follow you in the hospital after surgery,
along with your physician. The PA will review your discharge
instructions on the day after your procedure and facilitate your
discharge planning.
The day of surgery:
Several days prior to surgery you
will be contacted by the Same Day Surgery Unit's Nurse, who will
review your health and medication history. If you have not received a
call by 5:00 pm, the day before your surgery, please call
412-692-4990. Please be prepared and have a list of questions and your
medications by the phone.
You will be thinking of many things
on the day of your surgery, and it is only natural to be overwhelmed
and possibly confused about what to do. This information and other
information provided can help you become familiar with the process
involved with your hospitalization and surgery. We hope that these
help to answer your questions and reassure you about your procedure.
Arrival at the Hospital
Plan to arrive at Hospital on
the first floor. From the lobby area and follow overhead signs to
Admitting.
· Eating or drinking after midnight
the night before surgery is NOT permitted unless otherwise
instructed.
· You will be visited by a nurse
and/or PA, who will perform a preoperative assessment. You will sign
your surgical consent form.
· Results from your laboratory work
will be reviewed again.
· If you have a family doctor
clearance letter, it will be collected.
· Your back will be scrubbed by the
nurse in preparation for surgery, and you will go to the bathroom.
· Your family should wait in the
Surgical waiting room (located on the second floor outside the
Operating Rooms).
· After your preparation, you will go
to the Holding Area located next to the Operating Rooms.
Holding Area
Second Floor,
· This is an area just outside the
Operating Room.
Here, you will see your neurosurgeon
and discuss anesthesia with the anesthesiologist
· An intravenous, (IV) line will be
inserted, and you will be given antibiotics and fluids.
Operating Room
Second Floor,
· You will be in surgery for about
one to two hours. You will receive a general
anesthetic, which means, you will be
asleep during the procedure.
· After surgery, you will be taken to
the Recovery Room.
Recovery Room
Outside Operating Room
· Your vital signs will be checked
frequently, the surgical dressing will be checked and your symptoms
will be assessed.;
· You may receive pain medication.
· Your IV fluids will continue.
· You will not be allowed to eat or
drink.
· An anesthesiologist will discharge
you from the Recovery Room after you are completely awake, which
usually takes one to two hours.
· You then will be taken to the
Patient Unit
Your family will be informed as to
which Unit you will go to.
Patient Unit
· The nursing staff will assess you
on arrival to the floor and monitor your progress.
· Your IV line will be removed after
you drink fluids.
· You will be asked to take deep
breaths to prevent pneumonia and do ankle and calf exercises to
prevent blood clot complications. Pain medications is available; you
should ask for this if you need it.
· You will be assisted out of bed the
first time you get up. Then, you are encouraged to walk on your own in
your room and the halls.
· The nursing staff will remove the
operative dressing the morning after surgery and allow you to shower
with a plastic dressing covering this area.
Discharge
· Patients who have had lumbar
microdiscectomy are discharged the day after surgery. Your nurse and
PA will discuss your discharge instructions. Please prepare questions
to ask at this time.
· You will be given a discharge
instruction sheet that will include restrictions, activities, physical
therapy, medications and care of the incision.
· Remember to arrange your
transportation home prior to this day. You will not be allowed to
drive yourself home. If you anticipate a problem with your
arrangements to go home, please notify the staff the day of surgery.
The discharge time is before
11 am.
Most of the information you will need
about your stay is in a brochure you will receive or the UPMC
Information Handout, included in your admission packet. Pertinent
telephone numbers, directions, maps, lodging and parking information
are highlighted in the handbooks Your discharge instructions will help
you become familiar with any limitations you will have after surgery.
If you have specific
questions that are not addressed in these materials, please call your
neurosurgeon 412-630-7640 or 877-635-5234.
Call, toll-free, at 412-630-7640 or 877-635-5234 to learn more.
Patient Education
Lumbar Laminectomy: with
or without Fusion
Index:
Basic Information
Office Evaluation Information For
Patients
Lumbar Laminectomy: A Patient's Guide to
Surgery
Basic Information
Why you are here?
Most likely, the pain in your back or
legs, or both, ultimately led you to seek help. You have been
diagnosed as having lumbar spinal stenosis and will require Lumbar
Laminectomy. The condition of spinal stenosis results in the
narrowing of the spinal canal in which your nerves are contained. This
narrowing or stenosis and the pressure on the nerves can result in
pain, numbness and or weakness of one or both legs. These symptoms are
usually aggravated by walking and/or standing.
Often patients who have spinal
stenosis also have a condition called spondylolisthesis, or
slippage of one vertebral body over another. This also results in
nerve compression and associated pain and other symptoms. The degree
of "slippage" may cause spinal instability that would require a
fusion operation to be done at the time your stenosis is
surgically addressed.
Spinal stenosis, as pictured, can be
caused by a variety of reasons, including age, repetitive stress,
arthritis, thickening of the ligaments and a build up of calcium.
Some people are born with a narrow
canal which can become symptomatic with age and stress.
The Lumbar Laminectomy procedure is
designed to relieve this compression from the nerves. Generally, with
the nerves decompressed symptoms will improve. The surgeon reaches the
lumbar spine through a small incision in the lower back. Pressure is
relieved by partial or complete removal of the back portion of the
vertebrae called the lamina. The lamina is bone that covers the spinal
nerves or cord. This bony removal generally does not effect the
mobility or stability of your spine.
Spondylolisthesis
most often occurs as a result of degenerative changes, but can
likewise be seen secondary to trauma to the lumbar spine, or in those
patients who are post-laminectomy. The levels most commonly involved
are L4-5 and/or LS-SL. Risk factors for these changes to the spinal
column include prior spinal or abdominal surgery, obesity, prior
trauma or repetitive injury, and cigarette smoking.
Patients with degenerative
spondylolisthesis typically present with a long and slowly progressive
history of low-back and diffuse bilateral leg pain that increases with
ambulating. Patients will commonly say that the distance they are able
to walk has become shorter and shorter If the condition is left
untreated, it may simply become too painful for the patient to walk,
and they may then resort to the use of a wheelchair or other assistive
device.
Information For a Patient Referred of a
Office Evaluation
You have been referred to a
neurosurgeon for an evaluation that may result in having a surgical
procedure called Lumbar Laminectomy or Lumbar Laminectomy and Fusion.
Lumbar Laminectomy is designed to remove pressure from your spinal
nerves. Lumbar Laminectomy and Fusion is also done to relieve pressure
from the nerves and to stabilize the bony slippage. Most likely, after
surgery, you will return to the many activities you enjoyed before
your back problems occurred. If your evaluation indicates you are a
candidate for this surgery, the steps below will serve as a general
guideline from your first office visit to your return home.
Your first office visit
· Please remember to bring your
insurance information and a completed medical history form. You
should have received this form by mail or at the time of your visit.
This medical history form provides information about your current and
past medical history, along with any prior anesthesia complications,
your current medications and any drug allergies.
· Please bring the results of any
prior diagnostic test related to your condition. Also bring the actual
X-ray pictures from any computed tomography (CT) scan, magnetic
resonance imagining (MRI) scan, myelogram, plain X-rays or other test
that was done to evaluate your back problem.
Your examination
Your neurosurgeon and his staff will
interview you in the examination room. This will include a review of
the medical history form you have completed and questions about your
back problem. A comprehensive neurological and physical exam will be
performed, and any diagnostic tests and X-rays, will be reviewed.
Results of this exam may indicate the need for further-diagnostic
tests, conservative therapies or possible, surgical recommendation.
If Surgery is Required
· You may need to do several things
to ensure that your insurance company has approved, the operation
scheduled for you. Many insurance companies require
pre-certification and second opinions. It is your responsibility
to ask your insurance company about its particular requirements.
· If you have a pre-existing medical
condition and are under a doctor's care, you will receive a
consultation clearance form to be completed by your doctor. This
should be faxed by your doctor to your neurosurgeon's office as soon
possible, so surgery is not delayed. Also, plan to bring a copy of
this form to the hospital's Same Day Surgery Unit on the day of your
surgery.
Same Day Surgery
Fax: 412-692-2955
Phone: 412-692-2222
Testing before your Surgery
· On the day of your office visit,
you will receive a prescription for pre-surgical testing to detect any
blood abnormalities. These tests can be done up to 14 days prior to
your surgery date. The results must be reviewed by the neurosurgeon's
office no later than two working days before your surgery date. The
prescription allows any certified laboratory approved by your
insurance company, to do the blood and urine tests and forward
the results to the neurosurgeon's office for review.
· The same procedure is followed if
you require a chest X-ray and EKG. These tests, however, may need to
be done at your local hospital or doctor's office, because some labs
do not have these capabilities.
Pre-admission packet
· A pre-admission packet will
be given to you by the neurosurgeon's office on the day of your visit
or mailed to you if surgery is required.
Included in the packet is general information about the Hospital and
its procedures. Please read all of the pre-admission materials
completely. This brochure does not cover all the steps you'll need to
take on the day of your surgery.
Please read all hospital-related
materials.
Lumbar Laminectomy with or without Fusion: A
Patient's Guide to Surgery
You have been referred for a
procedure called Lumbar Laminectomy and/or Fusion.
Our goal is to return you to optimum
health following surgery
and send you home some time within the two to three days after your
operation.
The following information should help
you understand what will be involved with the surgery. This guide is
not intended to take the place of the neurosurgical team's
explanation, but is designed to answer some common questions and make
you familiar with common terms and procedures related to Lumbar
Laminectomy with or without Fusion.
Patients are considered for surgery
when efforts at conservative treatment have failed to relieve
symptoms. Conservative measures typically include physical therapy,
strengthening and conditioning exercises, back bracing, weight loss or
other lifestyle changes.
The Lumbar Laminectomy procedure is
designed to relieve this compression from the nerves. Generally, with
the nerves decompressed symptoms will improve. The surgeon reaches the
lumbar spine through a small incision in the lower back. Pressure is
relieved by partial or complete removal of the back portion of the
vertebrae called the lamina. The lamina is bone that covers the spinal
nerves or cord. This bony removal generally does not effect the
mobility or stability of your spine.
Patients who exhibit radiographic
evidence of spondylolisthesis, or slippage, are those most likely to
benefit from Lumbar Laminectomy and Fusion. Functional outcome
following this surgery is generally better and more rapid if the
patient is diagnosed early, and surgical intervention is accomplished
prior to muscle atrophy and an inability to ambulate secondary to
neural compression. Lumbar laminectomy is intended to decompress the
area of stenosis and the fusion (if required) is to prevent any
progression in the degree of spondylolisthesis and give stability to
the spinal segments. Generous foraminotoimies are performed in order
to decompress the neural foramina. Only rarely is it necessary to
realign the spine or reduce the slippage in non-traumatic
spondylolisthesis.
Fusion part, if required, uses pedicle screws and bone for
stabilization. These screws hold the spine in place until natural bony
fusion can occur in approximately three months. These screws, however,
are generally left in place even after the bony fusion has occurred.
Patients often ambulate with a brace the same day as surgery, so the
incidence of complications associated with immobility is greatly
reduced.
Testing and therapy before Surgery:
Conservative therapy or non-surgical
treatment is often used before surgery. Occasionally, conservative
therapy may relieve the symptoms associated with spinal stenosis and
eliminate the need for surgery. Because conservative therapies such as
bed rest, medications and physical therapy have not been effective for
you, your neurosurgeon has recommend Lumbar Laminectomy with or
without fusion.
Diagnostic tests such as lumbar
computed tomography (CT), magnetic resonance imaging (MRI) and
myelograms indicate the level degree of herniation and allow your
neurosurgeon to precisely perform the procedure. One or more of these
tests may be necessary to accurately diagnose the problem.
The Procedure and its Benefits:
Lumbar Laminectomy
takes about one to two hours to perform. Your incision will be about 3
to 6 inches long on the mid-low back area. Generally, you will be
walking the day of surgery and can be discharged one or two days after
your operation. Please arrange your transportation home in advance.
Lumbar Laminectomy with Fusion
takes about two to four hour and generally requires the above
laminectomy procedure first. The fusion is generally done with pedicle
screw and bone fusion.
The
risks involved with this type of surgery are: Infection, excess
bleeding, no relief of symptoms, excess scarring, increased
neurological dysfunction, anesthetic complications, and/or death.
After surgery, minor discomfort from
your incision is common but temporary. This can be relieved with mild
pain medication. Following the procedure, you may experience
persistent numbness, weakness and pain, but these symptoms are
generally temporary and gradually go away.
Discharge instructions will be
provided to you in a informational packet and review
with you prior to discharge.. Your activities will be limited until
you come for your postoperative follow-up visit.
Members of the health-care team:
You will meet a number of
health professionals during this time. Their goal is to help you
recover and return you to your prior activities. A brief description
of each of these professionals follows:
Neurosurgeon.
You have already met
this person, who will perform the surgery and direct your care
afterward. Please feel comfortable asking questions of your surgeon -
communication is an
essential key toward recovery.
Nurse.
A nurse will assess your
condition both in the surgeon's office and in the hospital. The office
nurse will evaluate you before you see the surgeon and again with the
surgeon at the time of your visit. The office nurse will help explain
the procedure, answer questions and arrange your surgery. The hospital
nurse will assess you in the hospital, and help you before, during and
after your surgery. The nurse also will answer questions from you and
your family.
Physician assistant.-
The physician assistant (PA)
has -been trained to perform many tasks done by a physician. The PA
may perform your history and physical examination and review the
surgical procedure. The PA can answer questions and will follow you in
the hospital after surgery, along with your physician. The PA will
review your discharge instructions on the day after your procedure and
facilitate your discharge planning.
The day of surgery:
Several days prior to surgery you
will be contacted by the Same Day Surgery Unit's Nurse, who will
review your health and medication history. If you have not received a
call by 5:00 pm, the day before your surgery, please call
412-692-4990. Please be prepared and have a list of questions and your
medications by the phone.
You will be thinking of many things
on the day of your surgery, and it is only natural to be overwhelmed
and possibly confused about what to do. This information and other
information provided can help you become familiar with the process
involved with your hospitalization and surgery. We hope that these
help to answer your questions and reassure you about your procedure.
Arrival at the Hospital
Plan to arrive at the Hospital on the
first floor. From the lobby area and follow overhead signs to
Admitting.
· Eating or drinking after midnight
the night before surgery is NOT permitted unless otherwise
instructed.
· You will be visited by a nurse
and/or PA, who will perform a preoperative assessment. You will sign
your surgical consent form.
· Results from your laboratory work
will be reviewed again.
· If you have a family doctor
clearance letter, it will be collected.
· Your back will be scrubbed by the
nurse in preparation for surgery, and you will go to the bathroom.
· Your family should wait in the
Surgical waiting room (located on the second floor outside the
Operating Rooms).
· After your preparation, you will go
to the Holding Area located next to the Operating Rooms.
Holding Area
Second Floor
· This is an area just outside the
Operating Room.
Here, you will see your neurosurgeon
and discuss anesthesia with the anesthesiologist
· An intravenous, (IV) line will be
inserted, and you will be given antibiotics and fluids.
Operating Room
Second Floor
· You will be in surgery for about
one to two hours. You will receive a general
anesthetic, which means, you will be
asleep during the procedure.
· After surgery, you will be taken to
the Recovery Room.
Recovery Room
Outside Operating Room
· Your vital signs will be checked
frequently, the surgical dressing will be checked and your symptoms
will be assessed.;
· You may receive pain medication.
· Your IV fluids will continue.
· You will not be allowed to eat or
drink.
· An anesthesiologist will discharge
you from the Recovery Room after you are completely awake, which
usually takes one to two hours.
· You then will be taken to the
Patient Unit
Your family will be informed as to
which Unit you will go to.
Patient Unit
· The nursing staff will assess you
on arrival to the floor and monitor your progress.
· Your IV line will be removed after
you drink fluids.
· You will be asked to take deep
breaths to prevent pneumonia and do ankle and calf exercises to
prevent blood clot complications. Pain medications is available; you
should ask for this if you need it.
· You will be assisted out of bed the
first time you get up. Then, you are encouraged to walk on your own in
your room and the halls.
· The nursing staff will remove the
operative dressing the morning after surgery and allow you to shower
with a plastic dressing covering this area.
If you have had a fusion you may
spend the first night in the Step-down Unit and then go to the regular
Nursing Unit.
If you already have a brace this can
be wore the first night after surgery. If you need a brace it will be
fitted and custom made for you to wear the following day.
A drain is sometime placed in the
wound after surgery in order to drain excess fluids. This will be
removed in one or two days.
Discharge
· Patients who have had Lumbar
Laminectomy are discharged one or two days after surgery. Your nurse
and PA will discuss your discharge instructions. Please prepare
questions to ask at this time.
Patients who also require a fusion
will be asked to wear a supportive brace for up to three months and
obtain monthly X-rays.
· You will be given a discharge
instruction sheet that will include restrictions, activities, physical
therapy, medications and care of the incision.
· Remember to arrange your
transportation home prior to this day. You will not be allowed to
drive yourself home. If you anticipate a problem with your
arrangements to go home, please notify the staff the day of surgery.
The discharge time is before
11 am.
Most of the information you will need
about your stay is in a brochure you will receive or the UPMC
Information Handout, included in your admission packet. Pertinent
telephone numbers, directions, maps, lodging and parking information
are highlighted in the handbooks Your discharge instructions will help
you become familiar with any limitations you will have after surgery.
If you have specific questions that are not addressed in these
materials, please call your neurosurgeon 412-630-7640 or 877-635-5234.
Call, toll-free, at 412-630-7640 or 877-635-5234 to learn more.
Patient Education:
Anterior
Cervical Discectomy with or without Fusion and Plating
Index:
Basic Information
Office Evaluation Information For
Patients
Anterior Cervical Discectomy: A
Patient's Guide to Surgery
Basic Information
Why you are here?
Most likely, the pain, numbness, or
weakness in your neck, arms, hands or legs, has ultimately led you to
seek help. You have been diagnosed as having a cervical herniated
lumbar disk and require an Anterior Cervical Discectomy. Disks are the
shock-absorbing cushions between the vertebrae of your spinal column.
These disks can herniate for a variety of reasons, including age,
stress, strain and sudden impact.
Herniation of the disk, as pictured
above, results in the soft inner contents of the disk pushing
through the fibrous outer wall and pressing, against the nerves that
run parallel to the spinal column. If the herniation is more central
the spinal cord can be compressed and cause symptoms down the entire
length of the spine and may include difficulty walking or incontinence
of the bladder or bowel functions.
Even slight movement can cause the nerve or spine to be irritated and
thus cause pain, numbness and weakness in the arms, hands or legs. The
Anterior Cervical Discectomy procedure is designed to remove this
herniated material from the nerves and relieve your symptoms.
This procedure is done through a small incision in the front of the
neck. There is minimal trauma to the neck tissues and the
intervertebral disk and or bone spurs are removed anteriorly to the
spinal cord. This approach allows for minimal spinal nerve or cord
traction and thus a quicker recovery period. Often a spinal fusion is
done by placing a small piece of bone in between the two vertebrae.
Occasionally, if the surgery involves more than one disc level or
there is significant spinal cord compression, the surgeon may need to
place a small plate (see picture) on the anterior cervical vertebrae
in order to give further spinal stability. If a fusion is done the
patient may need to be in a cervical collar or brace for several weeks
to allow complete recovery.
Information For a Patient Referred of a
Office Evaluation
You have been referred to a
neurosurgeon for an evaluation that may result in having a surgical
procedure called Anterior Cervical Discectomy. Anterior Cervical
Discectomy generally is performed to correct a herniated disk. Most
likely, you will return to the many activities you enjoyed before your
neck problems occurred. If your evaluation indicates you are a
candidate for this surgery, the steps below will serve as a general
guideline from your first office visit to your return home.
Your first office visit
· Please remember to bring your
insurance information and a completed medical history form. You
should have received this form by mail or at the time of your visit.
This medical history form provides information about your current and
past medical history, along with any prior anesthesia complications,
your current medications and any drug allergies.
· Please bring the results of any
prior diagnostic test related to your condition. Also bring the actual
X-ray pictures from any computed tomography (CT) scan, magnetic
resonance imagining (MRI) scan, myelogram, plain X-rays or other test
that was done to evaluate your disc problem.
Your examination
Your neurosurgeon and his staff will
interview you in the examination room. This will include a review of
the medical history form you have completed and questions about your
disc problem. A comprehensive neurological and physical exam will be
performed, and any diagnostic tests and X-rays, will be reviewed.
Results of this exam may indicate the need for further-diagnostic
tests, conservative therapies or possible, surgical recommendation.
If Surgery is Required
· You may need to do several things
to ensure that your insurance company has approved, the operation
scheduled for you. Many insurance companies require
pre-certification and second opinions. It is your responsibility
to ask your insurance company about its particular requirements.
· If you have a pre-existing medical
condition and are under a doctor's care, you will receive a
consultation clearance form to be completed by your doctor. This
should be faxed by your doctor to your neurosurgeon's office as soon
possible, so surgery is not delayed. Also, plan to bring a copy of
this form to the hospital's Same Day Surgery Unit on the day of your
surgery.
Same Day Surgery
Fax: 412-692-2955
Phone: 412-692-2222
Testing before your Surgery
· On the day of your office visit,
you will receive a prescription for pre-surgical testing to detect any
blood abnormalities. These tests can be done up to 14 days prior to
your surgery date. The results must be reviewed by the neurosurgeon's
office no later than two working days before your surgery date. The
prescription allows any certified laboratory approved by your
insurance company, to do the blood and urine tests and forward
the results to the neurosurgeon's office for review.
· The same procedure is followed if
you require a chest X-ray and EKG. These tests, however, may need to
be done at your local hospital or doctor's office, because some labs
do not have these capabilities.
Pre-admission packet
· A pre-admission packet will
be given to you by the neurosurgeon's office on the day of your visit
or mailed to you if surgery is required. Included in the packet is
general information about the Hospital and its procedures. Please read
all of the pre-admission materials completely. This brochure does not
cover all the steps you'll need to take on the day of your surgery.
Please read all hospital-related
materials.
Anterior Cervical Discectomy: A Patient's Guide to
Surgery
You have been referred for a
procedure called Anterior Cervical Discectomy.
Our goal is to return you to
optimum health following surgery and send you home the day after your
operation.
The following information should help
you understand what will be involved with the surgery. This guide is
not intended to take the place of the neurosurgical team's
explanation, but is designed to answer some common questions and make
you familiar with common terms and procedures related to Anterior
Cervical Discectomy surgery.
Testing and therapy before Surgery:
Our goal is to return you to your
activities prior to disability. Conservative therapy or non-surgical
treatment is often used before surgery. Occasionally, conservative
therapy may relieve the symptoms associated with a herniated disk or
other spinal problems and eliminate the need for surgery. Because
conservative therapies such as traction, medications and physical
therapy have not been effective for you, your neurosurgeon has
recommend Anterior Cervical Discectomy.
Diagnostic tests such as cervical
computed tomography (CT), magnetic resonance imaging (MRI) and
myelograms indicate the level degree of herniation and/or other spinal
problems and allow your neurosurgeon to precisely perform the
procedure. One or more of these tests may be necessary to accurately
diagnose the problem.
The Procedure and its Benefits:
Anterior Cervical Discectomy Fusion
takes about one to two hours to perform. Your incision will be about 2
inches long on the anterior side of your neck. Most patients will also
require a fusion and will need to wear a cervical collar for several
weeks.
The possible risks involved with this
type of surgery are: Infection, excess bleeding, transient or
permanent hoarseness, failure or
displacement of the bone plug (in cases where a fusion with bone is
required), increased neurological dysfunction, no relief of symptoms,
anesthetic complications and/or death.
Generally, you will be walking the day of surgery and can be
discharged the day after your operation. Please arrange your
transportation home in advance If you have any further questions
regarding these risks, please contact your surgeon.
After surgery, minor discomfort from
your incision is common but temporary. This can be relieved with mild
pain medication. Following the procedure, you may experience
persistent numbness, weakness and pain along the path of the nerve
that was decompressed, but these symptoms are generally temporary and
gradually go away.
Discharge instructions will be
provided to you in a informational packet and review with you prior to
discharge.. Your activities will be limited until you come for your
postoperative follow-up visit.
Members of the health-care team:
You will meet a number of
health professionals during this time. Their goal is to help you
recover and return you to your prior activities. A brief description
of each of these professionals follows:
Neurosurgeon.
You have already met
this person, who will perform the surgery and direct your care
afterward. Please feel comfortable asking questions of your surgeon -
communication is an
essential key toward recovery.
Nurse.
A nurse will assess your
condition both in the surgeon's office and in the hospital. The office
nurse will evaluate you before you see the surgeon and again with the
surgeon at the time of your visit. The office nurse will help explain
the procedure, answer questions and arrange your surgery. The hospital
nurse will assess you in the hospital, and help you before, during and
after your surgery. The nurse also will answer questions from you and
your family.
Physician assistant.-
The physician assistant (PA)
has -been trained to perform many tasks done by a physician. The PA
will perform your history and physical examination and review the
surgical procedure. The PA can answer questions and will follow you in
the hospital after surgery, along with your physician. The PA will
review your discharge instructions on the day after your procedure and
facilitate your discharge planning.
The day of surgery:
Several days prior to surgery you
will be contacted by the Same Day Surgery Unit's Nurse, who will
review your health and medication history. If you have not received a
call by 5:00 pm, the day before your surgery, please call
412-692-4990. Please be prepared and have a list of questions and your
medications by the phone.
You will be thinking of many things
on the day of your surgery, and it is only natural to be overwhelmed
and possibly confused about what to do. This information and other
information provided can help you become familiar with the process
involved with your hospitalization and surgery. We hope that these
help to answer your questions and reassure you about your procedure.
Please refer to the green Short
Procedure Unit brochure you will received for specific information
about when your surgery is scheduled and directions to the unit.
Arrival at the Hospital
Plan to arrive at the Hospital on the
first floor. From the lobby area and follow overhead signs to
Admitting.
· Eating or drinking after midnight
the night before surgery is NOT permitted unless otherwise
instructed.
· You will be visited by a nurse
and/or PA, who will perform a preoperative assessment. You will sign
your surgical consent form.
· Results from your laboratory work
will be reviewed again.
· If you have a family doctor
clearance letter, it will be collected.
· Your back will be scrubbed by the
nurse in preparation for surgery, and you will go to the bathroom.
· Your family should wait in the
Surgical waiting room (located on the second floor outside the
Operating Rooms).
· After your preparation, you will go
to the Holding Area located next to the Operating Rooms.
Holding Area
Second Floor
· This is an area just outside the
Operating Room.
Here, you will see your neurosurgeon
and discuss anesthesia with the anesthesiologist
· An intravenous, (IV) line will be
inserted, and you will be given antibiotics and fluids.
Operating Room
Second Floor
· You will be in surgery for about
one to two hours. You will receive a general
anesthetic, which means, you will be
asleep during the procedure.
· After surgery, you will be taken to
the Recovery Room.
Recovery Room
Outside Operating Room
· Your vital signs will be checked
frequently, the surgical dressing will be checked and your symptoms
will be assessed.;
· You may receive pain medication.
· Your IV fluids will continue.
· You will not be allowed to eat or
drink.
· An anesthesiologist will discharge
you from the Recovery Room after you are completely awake, which
usually takes one to two hours.
· You then will be taken to the
Patient Unit
Your family will be informed as to
which Unit you will go to.
Patient Unit
· The nursing staff will assess you
on arrival to the floor and monitor your progress.
· Your IV line will be removed after
you drink fluids.
· You will be asked to take deep
breaths to prevent pneumonia and do ankle and calf exercises to
prevent blood clot complications. Pain medications is available; you
should ask for this if you need it.
· You will be assisted out of bed the
first time you get up. Then, you are encouraged to walk on your own in
your room and the halls.
· The nursing staff will remove the
operative dressing the morning after surgery and allow you to shower
with a plastic dressing covering this area.
Generally you will be allowed to
remove your cervical collar for showering, but you must hold your head
and neck in a neutral position. Please discuss this procedure with
your nurse.
· You will be encouraged to ask the
staff any questions.
Discharge
· Patients who have had most patients
will also require a fusion and will need to wear a cervical collar for
several weeks. Instructions as to the care and application of the
collar will be provided. Generally you are discharged the day after
surgery. Your nurse and PA will discuss your
discharge instructions.
Please prepare questions to ask at this time.
· You will be given a discharge
instruction sheet that will include restrictions, activities, physical
therapy, medications and care of the incision.
· Remember to arrange your
transportation home prior to this day. You will not be allowed to
drive yourself home. If you anticipate a problem with your
arrangements to go home, please notify the staff the day of surgery.
The discharge time is before
11 am.
Most of the information you will need
about your stay is in a brochure you will receive or the UPMC
Information Handout, included in your admission packet. Pertinent
telephone numbers, directions, maps, lodging and parking information
are highlighted in the handbooks Your discharge instructions will help
you become familiar with any limitations you will have after surgery.
Call, toll-free, at
412-630-7640 or 877-635-5234
to learn more.
Lumbar
spine instrumentation
We are offering new hope for patients
suffering from mechanical back and/or leg pain secondary to spinal
cord or nerve root compression through lumbar spinal instrumentation,
or LSI. Patients most commonly present with a combination of spinal
stenosis and spondylolisthesis causing neural compression. Spinal
stenosis is most often seen in patients over 50 and is secondary to
degenerative changes that occur in the spine as a result of aging.
Spondylolisthesis most often occurs as a result of degenerative
changes, but can likewise be seen secondary to trauma to the lumbar
spine, or in those patients who are post-laminectomy. The levels most
commonly involved are L4-5 and/or LS-SL. Risk factors for these
changes to the spinal column include prior spinal or abdominal
surgery, obesity, prior trauma or repetitive injury, and cigarette
smoking.
Patients
with degenerative spondylolisthesis typically present with a long and
slowly progressive history of low-back and diffuse bilateral leg pain
that increases with ambulation. Patients will commonly say that the
distance they are able to walk has become shorter and shorter If the
condition is left untreated, it may simply become too painful for the
patient to walk, and they may then resort to the use of a wheelchair
or other assistive device.
Patients are considered for surgery
when efforts at conservative treatment have failed to relieve
symptoms. Conservative measures typically include physical therapy,
strengthening and conditioning exercises, back bracing, weight loss or
other lifestyle changes. This group of patients, who exhibit
radiographic evidence of spondylolisthesis, are those most likely to
benefit from LSI. Functional outcome following LSI is generally better
and more rapid if the patient is diagnosed early, and surgical
intervention is accomplished prior to muscle atrophy and an inability
to ambulate secondary to neural compression. LSI is intended to
decompress the area of stenosis as well as to prevent any progression
in the degree of spondylolisthesis. Generous foraminotoimies are
performed in order to decompress the neural foramina. Only rarely is
it necessary to realign the spine or reduce the slippage in
non-traumatic spondylolisthesis.
LSI was once thought to be too traumatic for the older patient.
Concerns with cardiac disease, pre-existing medical conditions or
blood pressure instability in a patient undergoing a lengthy and
complex operative procedure often precluded consideration of surgery
in the older patient. Our neurosurgeons can perform this surgery in
less than two hours and with minimal blood loss. Fusion rates have
been shown to be excellent with the use of pedicle screws for
stabilization until natural bony fusion can occur. Patients now
ambulate the same day as surgery, so the incidence of complications
associated with immobility is greatly reduced.
As a result of decreased operative time, early post-op ambulation and
adequate pain control, the length of hospital stay for patients
undergoing lumbar spinal instrumentation has decreased by 50 percent
since 1994. This reduction in hospital stay, combined with the low
incidence of postoperative complications, has resulted in a 40 percent
decrease in hospital costs.
Terms
Spondylolysis is a prerequisite for
spondylolisthesis. Spondylolisthesis occurs when spondylolysis weakens
one of the vertebrae so much that the bone slips out of place.
The condition can also be caused by degenerative disc disease. If the
vertebrae slip too much and begin to press on nerves, surgery may
become necessary. Spondylolisthesis may also be caused by degenerative
conditions that affect the vertebral joints, such as cerebral palsy.
Early treatment usually involves rest
and medication. Progressive spondylolisthesis usually requires
surgical treatment.
There are five types of
Spondylolisthesis - here are the three most common.
1. Type I is
called dysplastic spondylolisthesis and is secondary to a congenital
defect of either the superior sacral or inferior L5 facets or both
with gradual slipping of the L5 vertebra.
2.
Type II, isthmic or spondylolytic, in which the lesion is in the
isthmus or pars interarticularis, has the greatest clinical importance
in persons under the age of 50. If a defect in the pars
interarticularis can be identified but no slipping has occurred, the
condition is termed spondylolysis. If one vertebra has slipped forward
on the other (horizontal translation), it is
referred
to as spondylolisthesis.
3. Type III, is
a degenerative spondylolisthesis, and occurs as a result of the
degeneration of the
lumbar facet joints. The
alteration in these joints can allow forward or
backward vertebral displacement. This type of spondylolisthesis is
most often seen in older patients. In Type III, degenerative
spondylolisthesis there is no pars defect and the vertebral slippage
is never greater than 30%
Outcome Study
The last 80 patients who were treated
with LSI for
non-traumatic spondylolisthesis were an average age of 60. All these
patients underwent surgical fusion using TSRH pedicle screw fixation
with rods and crosslinks. Nearly all of the patients likewise had a
laminectomy and foraminotomy at the time of surgery. The average
length of hospital stay was 4.5 days, with 90 percent of the patients
then returning to their homes. Post-op complications were rare, with
no fusion failures and only six patients requiring transfusion. Seven
patients suffered postoperative infection, three of which were
superficial. Fifty-five of these patients had significant preoperative
weakness and of those, 91 percent were found to have improved strength
at their one-month post-op visit.
Preoperative imaging should include a lumbar myelogram with post-myelogram
CT scan. The sagittal CT images will show loss of enhanced spinal
fluid in the areas of profound compression as well as any resultant
nerve root compression. This serves to indicate which level or levels
require decompression. The myelogram with upright views will also
determine the degree of slippage of the vertebral bodies and the
degree of correction that is necessary to decompress the nerve root.
Overall, LSI generally is a safe and effective operation that is
feasible for nearly all patients diagnosed with symptomatic
spondylolisthesis who are refractory to conservative management. We
are committed to treating patients with the most severe and
challenging spinal disorders. Our outcomes data demonstrates that even
the elderly patient can achieve a safe and functionally improved
outcome.
The patient is positioned on the operating table in a prone position.
The incision is made over the anatomic position of the spinous
process.
When indicated, soft tissue and bony decompression are performed to
relieve neurological compression.
For a degenerative spondylolisthesis case, a blunt probe is inserted
through the pedicle and into the vertebral body.
Once the pedicle canals are prepared
and the screw length determined, the pedicle screws are sequentially
inserted.
The facet joint capsules are removed and cancellous bone graft is
placed into each facet joint. The transverse processes, and the
lateral walls of the facet joints are decorticated with high-speed
burs and curettes.
Corticocancellous bone graft taken
from the bone bank, along with any fragments of bone taken during
decompression are firmly pressed into the bone fusion bed.
Call, toll-free, at
412-630-7640 or 877-635-5234
to learn more.
Spinal Cord Tumors
Introduction:
Spinal cord tumors are rare but
can leave patients neurologically and functionally impaired. Recently,
improved testing, such as MRI and CTS, has allowed these lesions to
be diagnosed earlier and intervention can proceed sooner.
Microsurgical techniques and other specialized treatments can help to
minimize these potentially devastating types of tumors.
Types of Tumors:
Spinal tumors can be divided into extradural,
intradural extramedullary, and intradural intramedullary.
- Extradural- Those tumors outside the dural
covering of the spinal cord.
- Intradural extramedullary - Those tumors inside
the dural covering but not within the spinal cord itself.
- Intradural intramedullary - Those tumors inside
the dural covering and within the spinal cord itself.
The cell types of these tumors are the same are
those of the brain (See
list of tumor types). And many tumors from other parts of the
body can metastasize or travel to the spinal cord and cause
compression. Listed below are the common occurrence rates of the
following tumors that can occur within the spinal cord.
- Ependymoma (56%) The most common intrinsic spinal
cord tumor
- Astrocytoma (29%) These lesions are more common
in children than in adults.
- Oligodendroglioma (3%)
- Developmental tumors (3%)
- Hemangioblastoma (3%)
- Lipoma (2%)
- Others (4%)
Occurrence:
- Spinal tumors approximately 1.1 case per 100,000
persons.
- Approximately 15-20% of all central nervous
system (CNS) tumors occur in the spine.
- They occur in both the pediatric and adult
population.
- They are found most frequently in the thoracic cord but can also
occur in the cervical spine to the tail of the spine.
- A tumor can arise from any
component of the spinal cord.
- 90% are benign and therefore a surgical "cure" is
possible.
- Many are slow growing and take years to cause
problems.
- These tumors are occasionally missed in their
early stages because of their tendency to mimic other conditions.
(i.e.. back pain from strains or other traumatic injuries)
Symptoms and Signs:
Pain is the usual presentation and this is classically thought to
be worse when the patient is supine or flat. Pain usually radiates to
the part of the body (arm or leg) because theses nerves in the cord
are being pressed on by the tumor mass. Eventually weakness and
abnormal sensations will follow and the tumor advances and finally the
bladder and bowel will begin to lose normal function. During this time
walking will become difficult and paralysis may then rapidly occur.
Tests:
Some or all of the following tests maybe needed to
determine the extent and location of the tumor. It is also important
to determine if there are other locations of tumor both within the
spine or from other organs or tissues.
- Plain Spinal X-rays
- CTS with and without contrast dye
- MRI with and without
contrast
dye
MRA or MRI- angiogram
Myelogram
Electrical conduction tests - usually used during
surgery
Angiogram
Lumbar puncture
Treatment:
Once diagnosed a Neurosurgeon will need to assess
whether this is an operable tumor. If surgery is indicated the goal
will be to remove as much tumor safely and to preserve the
neurological function that is present prior to surgery. Many factors
go into this decision and the risks must be considered but once
surgery is agreed upon. Even with a successful outcome there is still
a possibility of reoccurrence which will usually require lifelong
monitoring with MRIs. Radiation therapy and chemotherapy are usually
of little help with most tumors of the spine but some treatment
protocols are offered.
Surgical Risks:
The possible risks from spinal cord tumor surgery
will be reviewed with you and your family prior to surgery. But this
type operation is obviously very serious and risks verses benefits
must be considered. The risk of paralysis, loss of bladder, bowel or
sexual function can occur but are rare in most cases. Spinal fluid
leaks, due to the fact that the dural or outer sac around the spinal
cord may be open, are more common and are treated with either prolong
bed rest or a spinal fluid drain after surgery. Recovery after this
type surgery may include aggressive physical therapy in order to
regain lost function due to the tumor compression. Cord swelling after
surgery is not unusual and symptoms may be worse for a time. Often
medications such as steroids are used to decrease nerve tissue
swelling. As with any operation events such as infection, blood clots
and pneumonia can occur following this type of surgery.
Case Study:
Complaint: This is a 25 year old man who
originally complained of mid to low back pain while working in July,
2001. He was treated with conservative therapy and his symptoms
worsen with pain radiating into his legs. MRI which showed a spinal cord tumor at the end
portion of the spinal cord.
Discussion: The symptoms and signs of spinal
tumors are usually slow to develop but often persist and worsen
despite treatment.
MRI Results:
Further review showed the spinal tumor at the level of T12 to L2 in
the spinal canal. It was intradural and intramedullary and up against
the conus medullaris or the tail of the spinal cord. It is
homogenously enhancing and had the appearance of an ependymoma. He was
examined and found to have decreased strength in his legs. He was
explained the risks and benefits of the recommended surgery.
Discussion:
Due to the consistent (same) appearance of the tumor throughout its
structure on an enhanced MRI, it was believed to be a
benign ependymoma tumor. Physical examination showed weakness of the
patients legs most likely from the enlarging mass of the tumor
pressing on the nerves as they exited the spinal cord to the legs. The
risks of surgical intervention, including but not limited to,
weakness, numbness, paralysis, and/or loss of bowel or bladder
function are always discussed in great detail.
Surgery:
The surgery consisted of T12 to L2 laminectomies and
opening of the dural sac surrounding the cord. (See above left
picture) The tumor was identified and resected from off of the nerve
roots very carefully. The tumor could then be removed. (See above
right picture)
Discussion:
The description above is minimal compared to the actual surgery
involved. This is a very intricate operation that requires great
skill and patience. The operating room microscope is used and
throughout the entire operation electrical monitoring is used to
monitor nerve function.
Operation:
The operation was a success and the patient recovered completely and
was discharged home 3 days after the surgery. The patient complained
of some incisional pain but his leg symptoms and strength had returned
to normal. Post-operative MRI examination prior to hospital discharge
showed no residual tumor.
Discussion:
The results are typical but as with any operation results can vary.
This patient would be able to resume most activities in 1 to 2 months,
including work activity. This type tumor can reoccur and therefore
follow-up MRIs are recommended annually.
Call, toll-free, at 412-630-7640 or 877-635-5234 to learn more.
Introduction:
Primary brain tumors are tumors that
arise from cells originating in the tissue of the brain and skull.
Primary brain tumors rarely spread to other areas of the body, but
they can spread to other parts of the brain and to the spinal.
Prognoses of primary brain tumors are determined by histologic type
(cell type), grade of malignancy, and extent of the tumor and by the
patient's age, the performance status, and the duration of symptoms.
Some primary brain tumors are curable by surgery alone, and some are
curable by surgery, chemotherapy. and radiation therapy. The
postoperative size is often the most important factor in the prognosis
equation. Dr. Maroon and his associates are experts in the delicate
surgery required to remove complex brain tumors, and allow for the
greatest chance of survival.
Surgery:
Surgical removal of brain tumors is
generally
