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How spine surgery has changed in the past 10 years


Spine surgery is not what it used to be even as recently as 2000s. Rapid technological advances in spine surgery and development of new (mainly minimally invasive) techniques have elevated spine care and spine surgery to levels hard to keep up with for most spine surgeons and neurosurgeons. Before 2010, understanding of spinal biomechanics was minimal. Fusion surgeries were at their peak, but it turns out, they were not done correctly. We had no knowledge, at that time, that simply placing a "cage" into a degenerated disc space and "fusing" that disc space had the potential to destabilize the spine and cause more problems down the road. Patients became "better" for about 3 or 6 months, and then their back pain returned (mainly from accelerated degeneration of the adjacent level due to "flat back" introduced by the previous fusion). This led to further surgery and a "Catch 22" phenomena where each fusion led to a problem at the next level, then the next, etc. Surgeons knew that fusion was not a good long-term solution, but did not understand why.

Recent research in this area has produced a lot of answers as to why spine fusions fail requiring revision surgeries, and what can be done to minimize that risk. Unfortunately, this information is still not well adopted by most surgeons (or even understood). Older surgeons are simply "comfortable" with their practice and frankly quite resistant to change. New surgeons not fellowship trained in complex spine surgery are still oblivious to this, especially since this information was not introduced to the American Board of Neurological Surgeons (ABNS) certifying exams until only two years ago (2016). It turns out, even a laminectomy (let alone a single level fusion) has the potential to destabilize the spine and increase the risk of failure and the need for future revision surgery, unless patient's spino-pelvic parameters are calculated and maintained throughout the operation. For example, a one level "interbody" fusion for a degenerated disc in a patient with leg and back pain can reduce the normal spinal curvature at that level by 3-5 degrees (even if a special "hyper-curved" (aka lordotic) cage is used). This is also called "flattening out" of the back at that level, meaning, the disc at the level above or below takes extra amount of force to compensate for this "flattening" therefore causing instability. This leads to accelerated degeneration of the rest of the spine culminating in return of the back pain and the need for future revision surgery in as little as 3 to 6 months.

Revision surgery is not easy. It is not simply treating the next degenerated level, but many times, restoring the natural curvature and alignment of the spine. Not many surgeons know how to correct spinal deformity and such patients end up not only living with chronic pain but also being turned away from one surgeon to the next, culminating with chronic pain management and injections which simply stop working after some time. Knowledge of the spinal biomechanics, evaluating each patient separately, and calculating each patient's individual spino-pelvic parameters is at the least the most important step in performing spine surgery correctly. The next step is for the surgeon to be actually skilled enough to do so in the operating room, which requires proper training.

Discoveries in spinal biomechanics and spino-pelvic alignment are what made spine surgery so different than only 10 years ago. Most surgeons haven't had time to adopt to this information yet, however. In fact, this knowledge is so recent that finding a "good" spine surgeon actually goes against the common sense: it is often the younger surgeons, not the older or the more established, who are often aware of these changes and skilled enough to do them. While this may be true for some, it certainly is not true for everyone. There are many young surgeons who do not understand these basic concepts of spine surgery and also many older surgeons who are actually the ones who were part of the research and who have designed the new techniques and instrumentation. How to find the right surgeon, however, is beyond the scope of this blog. But as a patient, being aware of this, already puts you ahead of many.

Lastly, minimally invasive (MIS) spine surgery, has come a long way in treating patients requiring revision surgery, maintaining proper spino-pelvic balance, and simply being equivalent to open surgery when treating complex (and also not so complex) spine deformity and back problems. In the past, MIS surgery was simply used to treat degenerative disc disease. Since the introduction of new "anterior column realignment (ACR)" techniques in 2012, MIS surgery is now seen as equivalent to open spine surgery in the area of complex spine deformity correction, while at the same time reducing blood loss, complications, and length of recovery. The so called XLIF or OLIF techniques, which you may have heard of in the past, are what spine surgeons talk about interchangeably when speaking to patients. The equivalency of either of these techniques to each other has not yet been established, but that is beyond the scope of this blog. Frankly, at this time, it does not matter what technique is used but who is using it.

Spine surgery is perhaps the fastest changing subspecialty in Neuro-spine and Orthopedic spine surgery. It is growing faster than most surgeons can adopt to, perhaps making surgeon selection the most difficult for the patients with surgical back pain. However, I hope that by simply understanding what your doctor must know before he picks up a knife and makes an incision on your back, will help you make a more informative decision about your consultation.

As always, feel free to email me any questions, concerns, or comments. I try to reply to everyone or blog/webcast about it to reach as many as I can.

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