When a severe back or neck condition fails to respond to more conservative therapies and treatments, a minimally invasive, surgical procedure or fusion may be recommended. Information for the fusions we perform is listed below.
The DLIF (Direct Lateral Interbody Fusion) procedure involves a small skin incision in your side (therefore, direct lateral). Using minimally invasive surgical techniques, the neurosurgeon separates muscles (psoas muscle) and soft tissues to access the intervertebral disc. Because access to the spine is through the psoas muscle, DLIF is sometimes called a trans-psoas LIF or approach.
The goals of a lumbar spinal fusion procedure are to strengthen the spine and prevent painful movements and is used to treat back or leg pain caused by degenerative disc disease. The surgeon will stabilize the spine by fusing vertebrae together with bone graft material. Typically, both are achieved by removing one or more damaged intervertebral discs and then "fusing" together the adjacent vertebrae utilizing bone grafts and/or metal devices secured by special screws.
This surgery is commonly performed for isthmic spondylolisthesis, degenerative spondylolisthesis, degenerative scoliosis, multiple recurrent disc herniations, and chronic discogenic low back pain. Conservative measures such as physical therapy, steroid injections, anti-inflammatory medications, and activity and job modifications should be tried at length before the surgery is entertained.
The fusion may take the form of posterolateral fusion, anterior fusion, posterior interbody fusion, or combination of these procedures. Pedicle screws are almost always used to immobilize the fusion area while the fusion is taking place. It takes about 6 months for the fusion to consolidate and smoking severely interferes with this process. Circumferential fusion or 360 fusion in the form of anterior posterior fusion or combined posterolateral and posterior interbody fusion may be performed in smokers to increase the fusion success rate.
Posterolateral lumbar fusions usually take about 4 hours. Combined or circumferential fusions take additional two hours.
Success rate of the surgery vary depending on patient's diagnosis. Usually 80 to 90 % success rate is achieved in isthmic spondylolisthesis, degenerative spondylolisthesis, degenerative scoliosis, and multiple recurrent disc herniations. Success rate is lower in lumbar fusions treating chronic discogenic low back pain syndrome.
Complications of the surgery include about 1 to 2% chance of return back to operating room for pedicle screw malpositioning, a small risk of nerve injury, about 3 % chance of wound infection, excessive bleeding, and other medical complications such as postoperative pneumonia or heart attack. Very rarely epidural hematoma causing paralysis can occur if patients had been taking blood thinners immediately prior to surgery. Therefore patients should stop taking all types of blood thinners such as coumadin and anti-inflammatory medications including Vioxx and Celebrex at least one week prior to surgery.
Hardware complications such as broken rods or screws can occur. Fusion may not heal requiring additional surgery later on. At times levels adjacent to the fusion area may wear out gradually causing so-called transitional syndrome requiring another operation, usually extension of fusion later on. This is more common more levels are fused. With one level fusions the incidence is 5% or less. Pedicle screws are FDA approved for treatment of degenerative and isthmic spondyloisthesis and fractures of lumbar spine but not for other indications and patients should be aware of these. The screws have been in use for more than 20 years. The screws greatly enhance fusion success rate and they are essential and indispensable in achieving successful fusion in this surgeon's opinion. To further enhance fusion success interbody devices such as cages or structural allograft bone may be used in the disc space.
Patient's own bone is used for the fusion and this is usually taken from the posterior iliac crest. This is usually obtained using the same incision as the fusion surgery. In some patients bone graft donor site pain can be severe but in most of the cases this is not a real problem. Patient's own bone works best but if it is lacking for various reasons bone substitute which is both osteoconductive and osteoinductive may be used. For postop recovery information please refer to a separate heading in this web site.
Transforaminal Lumbar Interbody Fusion (TLIF) is a surgical technique to stabilize the spinal vertebra and the disc or shock absorber between the vertebra. Lumbar fusion surgery is designed to create solid bone between the adjoining vertebra, eliminating any movement between the bones. The goal of the surgery is to reduce pain and nerve irritation.
Spinal fusion may be recommended for conditions such as spondylolisthesis, degenerative disc disease or recurrent disc herniations. Surgeons perform lumbar fusion using several techniques. This article describes the transforaminal lumbar interbody fusion (TLIF) fusion technique.
Procedure for Spine Fusion Using TLIF Technique
- TLIF back surgery is done through the posterior (back) part of the spine.
- Surgical hardware is applied to the spine to help enhance the fusion rate. Pedicle screws and rods are attached to the back of the vertebra and an interbody fusion spacer is inserted into the disc space from one side of the spine.
- Bone graft is placed into the interbody space and alongside the back of the vertebra to be fused. Bone graft is obtained from the patient's pelvis, although bone graft substitutes are also sometimes used.
- As the bone graft heals, it fuses the vertebra above and below and forms one long bone.
Oblique Lateral Lumbar Interbody Fusion, or OLLIF, is a truly minimally invasive interbody spine fusion. A revolutionary quantum leap in spine surgery, we are the first in Midwest to perform OLLIF. Currently offering the procedure in Alexandria and Crookston, it's done via multiple incisions, each half an inch long, without cutting or separating muscle from bone. This makes recovery much quicker and puts patients back to regular life much faster than traditional open surgery. "Keeping it simple" is great advice for many aspects of life—even when it comes to things as complex as back surgery.
When non-surgical and conservative treatments fail, surgery may be required. Shouldn't this experience be as gentle and easy as possible? With our state-of-the-art techniques, we are pleased to offer the most advanced minimally invasive approach to spine surgery.
While every back patient's medical needs are unique, the full scope of compelling benefits offered by the OLLIF procedure is available to many patients considering a lumbar fusion procedure.
- A convenient, outpatient environment is often available, which means hospitalization may be not be required.
- Less blood loss than traditional methods is typical among patients . Smaller incision sites
- Less time spent in the operating room than traditional surgery, promoting faster recovery. Typically, an OLLIF procedure takes less than 90 minutes.
- A minimally invasive and minimally disruptive experience, resulting in many patients finding they are able to get up, walk around and return home within a few hours of surgery. Typically OLLIF patients return to normal recreational activities in a few weeks.
Since the OLLIF procedure is designed to avoid any major muscles and preserve healthy, natural structures, the procedure may result in less pain and trauma to the back, promoting a faster recovery. Typically OLLIF patients return to normal recreational activities in a few weeks.
This is a minimally invasive technique of doing anterior interbody fusion of lumbar spine from L1 to L5. L5 S1 fusion cannot be done due to the fact that the iliac crest is in the way. The approach could be extended to include the thoracic spine. For more detailed information and video animation of the surgery please check out the website www.lateralaccess.org.
The approach is done through a small about one inch or so incision in the flank or side of the abdomen. Blunt wand is introduced behind the abdominal cavity through the psoas muscle to dock onto the lateral aspect of the lumbar disc spaces. During the approach electronic monitoring is performed to make sure that nerves in the psoas muscle are out of the harms way. Intraoperative x ray called fluroscopy is essential to guide the wand to the correct spot at the side of the disc space. Once it is positioned in good location a pin is inserted through the wand into the disc space and series of dilators are used to enlarge the access portal. Finally extremely well designed self retaining long retractor with fiberoptic light is inserted and secured into a rigid position and all subsequent work is done through the portal established by the retractor.
Disc material is then removed and is replaced by either titanium or absorbable cage packed with either patient's own bone or synthetic bone graft material. After that either a side plate may be applied or patient can be repositioned to apply posterior fixation and/or posterior bone graft.
There is very little blood loss from the procedure. The recovery is quite rapid especially if the side plate is used without the posterior procedure.
Complications include thigh pain related to penetration through the psoas muscle at times associated with numbness. The discomfort usually is temporary but at times can be long lasting or permanent. Other complications include uncontrollable bleeding, risk of neurological injury, infection, and risk of fusion not healing requiring subsequent surgery. In general surgery is very well tolerated by patients.
The goal of an anterior cervical decompression and fusion (ACDF) surgical procedure is to treat severe nerve root or spinal cord compression by decompressing the nerve roots of the cervical spine in order to stabilize the corresponding vertebrae. This procedure is typically utilized when other non-surgical treatments have consistently failed.
This procedure uses an anterior (from the front of the neck) approach of the spine at the affected levels. First, the intervertebral disc(s) that is/are causing the problem is removed. This is commonly referred to as a discectomy. Then the empty space is filled with bone graft. This allows a fusion to occur. A fusion occurs when the bones grow together creating a bond between the two vertebrae. A plate is then positioned over the bone graft to provide immediate, temporary stability for the anterior cervical spine while the bone graft (s) try to fuse. The plate is attached to the affected levels using screws. Plates may potentially be used in patients who have received a diagnosis from their doctor of degenerative disc disease, trauma, tumors, deformity, pseudoarthrosis and/or a failed
There are potential risks associated with the use of these devices some of which include: disassembly, bending, and/or breakage of any or all of the components, pressure on the skin from the plate which could cause skin penetration, irritation, and/or pain, tissue or nerve damage, scar formation, interference with imaging of the area, and other risks.
This surgery is commonly performed for radiculopathy causing persistent arm pain with weakness and numbness or myelopathy causing weakness of upper and/or lower extremities. Depending on what's done surgery may take one to four hours.
Success rate of this surgery is usually 90% in relieving patient's arm pain. Weakness and numbness may improve even though at times this is unpredictable especially if there is irreversible nerve damage or spinal cord damage present prior to surgery.
Patients are usually sent home in one to three days. Titanium plate is used in addition to structural allograft bone available from various spine implant companies. Patients are asked to wear neck collar from 6 weeks to 3 months depending on what's done.
There is not much pain associated with this surgery. A transverse incision is made on the left side of the neck and the surgeon works between esophagus/trachea complex on one side and carotid artery on the other side. These structures are carefully protected using special retractors during the surgery. Power drill is used to shape the interspace and decompression of either the nerve root or spinal cord is performed and after that a bone graft of appropriate dimension is chosen and inserted into the interspace and metallic plate is applied on top of it using tiny screws.
Blood loss is minimal unless corpectomy (removal of entire vertebra) is performed. Wound infection is rare. Sore throat and swallowing difficulty is expected but this resolves in a week or two even though when extensive dissection is necessary such as revision cases swallowing difficulty with certain kind of food may become permanent. Hoarseness of voice due to injury to the recurrent laryngeal nerve of the voice box can occur but the incidence is greatly reduced by approaching the spine from the left side as opposed to from the right side. The incidence from the left side is less than 1%. Depending on the situation such as nerve injury or paralysis can occur but these are quite rare unless the spinal cord is so compromised to begin with such as is the case in quadraparetic patients with spinal cord myelomalacia and OPLL( ossified posterior longitudinal ligament). In the latter case risk of paralysis can be substantial and intraoperative spinal cord monitoring is used for the surgery. Other potential but rare complications of the surgery include injury to esophagus, trachea, and vertebral artery.
In general cervical spine surgery is better tolerated and long term results are better than lumbar spine surgery. Conservative care such as physical therapy and cervical epidural steroid injections are encouraged prior to surgery except in cases of myelopathy with spinal cord compromise and in the latter situation only surgery may help.
Posterior cervical decompression and fusion surgery removes the lamina, thickened ligament, and/or bone spurs that are putting pressure on the spinal cord and nerve roots. This compression is a result of a herniated or degenerated disc, spinal stenosis, and/or spinal instability. Nerve compression can lead to pain in the neck and arms, lack of coordination, and numbness or weakness in the arms.
Patient's head is held in a special gear called Mayfield head holder with 3 pins going into the skull. A midline incision is made in the back of the cervical spine. Muscles are pushed apart exposing the bone. Either bone spurs or discs are removed that are pinching the spinal cord or nerve root. For fusion bone is harvested from a separate incision over the posterior iliac crest and screws and rods are commonly used. Screws are not FDA approved. After surgery neck is placed into a neck collar for about 3 months.
Risks of the surgery include nerve injury, paralysis, bleeding, and wound infection. Fusion may not occur requiring further surgery at a later time. Hardware complications such as screw malpositioning with nerve root injury requiring reoperation may occur. At times symptoms may persist despite seemingly successful surgery for various reasons.
After surgery, a hospital stay is usually required. Complete recovery time may take between eight and twelve weeks. Although complications are rare, any surgical procedure carries risks. Possible risks include infection, bleeding, reactions to anesthesia, injury to the spinal cord, pain at the treated site, damage to nerves or arteries, blood clots and paralysis. These risks can be minimized by choosing an experienced surgeon to perform your procedure, and by adhering to your surgeon's instructions before and after your procedure.
Patients should not use any type of anti-inflammatory medications such as aspirin, Naprosyn, Vioxx, Celebrex as these medications can interfere with spinal fusion process.
Smoking is also discouraged as it can "melt away" the fusion.
The Sacroiliac Joint Fusion System
The Sacroiliac Joint Fusion System is a minimally invasive surgical (MIS) procedure for patients with sacroiliac (SI) joint dysfunction and/or inflammation (sacroiliitis) who have not gained relief from conservative care. This System is the only MIS process with the proprietary Decorticator® that allows surgeons to prepare the articular region of the joint and insert bone graft into the joint to help facilitate a true bone fusion. This procedure enables a more rapid return to regular activities for patients and a greater potential for a successful SI joint fusion.
This System is the only minimally invasive SI joint fusion system that includes all three critical steps to achieve true bone fusion across the SI joint:
- Decortication – preparing the bone surface to trigger the body's natural healing response.
- Bone grafting – filling the space between bones with material the bone may grow across.
- Fixation – placing threaded implants that prevent the joint from moving during the healing process.
- Minimal incision size
- Immediate post-operative stabilization
- True bone fusion, by creating the conditions that ensures bony growth across the SI joint
- Potential for a rapid recovery
About the sacroiliac (SI) joint
The sacroiliac joints are strong joints (or articulations) between the bottom-most triangular bone of your spine, called the sacrum, and the ilium sections of the pelvis (the sections of the pelvis you put your hands on when you put your hands on your hips).
The function of the sacroiliac joint is both shock absorption (depending on the joint's possible amount of movement) and torque conversion, to transfer movement in your lower body up to your spine.