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All Posts Tagged: Spine

Percutaneous spine surgeries

 

 

In modern surgery, with the help of technology and the accumulation of experience, new methods have been developed, which help surgeons perform operations that in the past were particularly traumatic, with minimal risk of surgical trauma. A typical example is spine surgeries, such as spinal fusion.

 

Percutaneous spine surgeries significantly reduce patients’ discomfort, pain, risks and hospitalization time. Thus, even the largest spinal fusion does not mean that the patient is required to stay in bed. Patients with spondylolisthesis, spinal stenosis, lumbar spondylosis, and vertebral fractures after injury can move without pain within a few days and are discharged from the hospital in 2-3 days. This is because neither the back muscles nor the bones and ligaments are injured, so the pain is comparatively minimal. The need for blood transfusions during spinal fusion surgeries is practically zero.

All open spinal fusions can be replaced by percutaneous ones, with the mere exception of surgeries to repair scoliosis. The time of full functional recovery is dramatically reduced by reducing the cost of health expenditures at individual and national level.

Microdiscectomyis a case of day care, while the incision in the skin is less than 2 cm. The patients do not even have to spend the night in the hospital. Thus,recovery is accelated and they are able to return to their activities.

Percutaneous kyphoplasty , for the repair of vertebral fractures (eg from osteoporosis), is also performed with daily hospitalization and immediate mobilization and relief of the patient.

These methods utilize technologies such as robotic navigation, neuronavigation, surgical microscope and endoscope, as well as a number of advanced surgical tools and equipment , such as the ultrasonic osteotomy. Surgeons who know these techniques, can offer patients the surgical care of the 21st century in Greece , with the exact same quality characteristics as in the most advanced medical countries in the world.

Open spine surgery  

 

Percutaneous surgery. See how small the skin opening and the overall surgical injury are

Open spine surgery. Percutaneous surgery

See how small the skin opening and the overall surgical injury are

Kyphoplasty surgery to repair a vertebral fracture

Kyphoplasty surgery to repair a vertebral fracture

Patient with spondylolisthesis between 4th and 5th lumbar vertebrae Rehabilitation with percutaneous spinal fusion and implant in the disc. The spondylolisthesis has been redone.
Patient with spondylolisthesis between 4th and 5th lumbar vertebrae Rehabilitation with percutaneous spinal fusion and implant in the disc. The spondylolisthesis has been redone.
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Pain Treatment with Radiofrequency Electrode Application

 

 

Radiofrequency therapy is indicated for the treatment of  neuropathic pain, neuralgia, but also persistent musculoskeletal pain such as sciatica, low back pain and neck pain, which is continuous, has an anatomically clear distribution and is resistant to conservative treatment (medicines, patches, etc.).

Neuropathic pain can be treated with the use of radiofrequency. Examples of such diseases are postherpetic neuralgia and trigeminal neuralgia.

An example of non-neuropathic pain that can be treated with radiofrequency is back pain due to degeneration of the vertebral joints, as well as selected cases of neck pain.
The use of radiofrequency is not indicated when the pain is of central etiology, i.e. the nervous system damage is located in the brain or the spinal cord.
The radiofrequencies are applied via an electrode to the active tip of a special needle, using a continuous electric field, which causes the controlled production of heat through the friction of ions. When this heat (60-90 ° C, depending on the indications) acts on a target nerve, it provokes its selective destruction and modification, with the aim of stopping the transmission of painful signals to the spinal cord and brain, thus pain relief.

The electric radio frequency field is generated by a special radio frequency generator and is applied to the target through a special needle with an active non-insulated tip. An electrode connected to the generator enters into this special needle. The generator has an indication screen and provides detailed information regarding the various parameters of the operation.

 

DESCRIPTION OF THE SURGERY (MAINLY CONCERNING THE SPINE)

The operation is performed under local anesthesia and twilight anesthesia, with X-ray guidance (C-arm). The patient does not need to spend the night in the hospital and can go home just a few hours after the end of the operation (day care).

After all the antiseptic measures have been taken, a special needle is directed with absolute precision towards the target. We use radiographic guides, taking multiple profile, face and oblique shots, so that the needle and the electrode can navigate between the sensitive structures and away from blood vessels, the spinal cord, the dura mater and the internal organs (eg the lungs, in medial nerve access).

When the final correct position is confirmed radiographically through various shots, a contrast agent is administered to erase the contour of the nerve and its extension into the spinal canal (in case the surgery is performed inside the spine). The special electrode is then connected to the radio frequency generator.
An aesthetic test with nerve stimulation follows, using specific intensities (μA), voltages (mV) and frequencies (Hz), in order for the active tip of the needle to be placed as close to the target as possible (ie to the sensory area of the nerve). Once this is achieved and the measurements of the above parameters and tissue resistance (Ω) are satisfactory, a motor testing follows and the patient’s response to this type of stimulation is observed to ensure that the active needle tip is at a safe distance from the motor nerve that is not a target. This is a particularly delicate process if we consider that the tip of the electrode is usually 1.4 mm in diameter, while the diameter of the nerve can range from 2-5 mm. The target nerve is obviously in close proximity to the motor branch and its artery and vein, so absolute certainty is required before the treatment application, in order to avoid complications.
The electrode is then heated in a controlled selected temperature, for a few minutes (1 to 2.5 minutes, depending on the therapeutic protocol) exerting its therapeutic effect. The rise in temperature is not painful for the patient because during thermocoagulation the anesthesiologist administers twilight anesthesia and systemic central analgesia. In most cases, applying heat to a sensory nerve would be particularly painful, without continuous anesthesia. A typical operation takes 30-90 minutes, as thermocoagulation of more than one sensory branch may be required. Access may also be difficult due to anatomical abnormalities in the area (eg significant osteophytes, or anatomical variants).

 

RESULTS

Radiofrequency therapy is a safe and effective method of treating several chronic painful syndromes. If the pain is significantly reduced with the first application of radiofrequency then the treatment can be repeated more times. There is strong clinical evidence that radiofrequency therapy is effective in treating trigeminal neuralgia, radicular nerve pain, and spinal pain (Lord 2002). In a large study, 92.5% of patients with trigeminal neuralgia reported excellent or good relief after treatment of the trigeminal ganglion with traditional radiofrequency (Chen 2001).
The denervation of the facet joints in the lumbar and cervical spine, with the application of radiofrequency in the medial nerve branch is documented by large studies (RCT studies). A recent  review for the invasive treatment of chronic spinal pain by the American Society of Interventional Pain Physicians (ASIPP)  concludes that denervation of the lumbar and cervical joints of the spine is highly effective in a short period of time (3-6 months) and moderately documented for a long period of time (>>1 year).

After treatment, patients are usually relieved of the need for continuous analgesic treatment and all the possible side effects and ineffectiveness it may bring, while fully returning to their activities without any restrictions.

Especially in the case of denervation of the facet joints in the lumbar and cervical spine, the absence or reduction of pain (i.e. backache or neck pain), allows other therapeutic actions to be performed (i.e. physical therapy for muscle strengthening) which have a continuous and long-lasting effect as far as the reduction of pain episodes is concerned.

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Postoperative chronic pain

 

 

This category includes a number of conditions such as the so-called failed back / failed neck pain syndrome. Many of these patients continue to suffer from pain, although clinical and imaging tests (X-rays, MRI scans, etc.) do not identify any cause of their pain.

Implantation of spinal cord stimulators in the spine

Postoperative chronic painIn selected cases , implantation of spinal cord stimulators in the spine may help.The correct diagnosis of the syndrome made by specialized doctors (anesthesiologists, neurologists, or neurosurgeons) and the correct choice of patients who may benefit from it is a prerequisite. The stimulator is implanted in the patient’s body, usually in the abdomen. After a short period of training it can be used by the patients themselves through a simple remote control, depending on the intensity and location of their symptoms. It significantly improves symptoms by controlling pain in the exact area where it occurs. The implant operation is relatively simple. The surgery lasts 30-45 minutes, under general anesthesia, and the duration of postoperative treatment is 2-3 days. The use of the system can start during the hospitalization of the patient and its beneficial effects are immediately felt. About 2 in 3 patients in this category are relieved of their symptoms and no longer need to take chronic medication with all its possible side effects.

 

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Minimally Invasive Neurosurgery

Neurosurgery techniques have been developed in order for operations to be performed with the least possible risk of body injury. Especially in Neurosurgery, where the object of treatment is the valuable nerve tissue, which if damaged can not be regenerated, the minimally invasive technique is really valuable for patients.

Minimally Invasive Methods utilize technologies such as Robotic Navigation, the Surgical Microscope and Endoscope , as well as a range of advanced surgical tools and equipment, such as the ultrasonic osteotomy. Surgeons who know these techniques are able to provide patients with modern surgical care in Greece, with the exact same quality characteristics as in the most advanced medical countries in the world.

Now even the most inaccessible anatomical areas can be operated on with minimal injury to sensitive nerve structures.

Minimally invasive spine surgery. Fashion or real progress?

In modern surgery, with the help of technology and the accumulation of experience, new methods have been developed, which help surgeons perform operations that in the past were particularly traumatic, with minimal risk of surgical trauma. In most surgical specialties, such as gynecology, urology, general surgery and others, the non-use of endoscopic and minimally invasive techniques for some surgeries tends to be considered bad medical practice (malpractice).

In many cases, all of these methods tend to replace open surgeries.

Minimally invasive spine surgery.

There is clear pressure coming from insurers, both private and public, as well as from the patients themselves for access to medical intervention which, while not lagging behind in terms of effectiveness, will be clearly more economical, and will restore the patients’ help, ensuring a better life overall.

The progress of spine surgery A typical example is spine surgeries, such as spinal fusion. Percutaneous spinal surgeries, for example, significantly reduce patients’ discomfort , pain, risk of complications, and hospitalization time. Even the largest spinal fusion does not mean that the patient is required to stay in bed. Patients with spondylolisthesis, spinal stenosis, lumbar spondylosis, and vertebral fractures after injury can move without pain within a few days and are discharged from the hospital in 2-3 days. The need for blood transfusions during spinal fusion surgeries is practically zero.

The purpose of minimally invasive techniques is to prevent injury of the muscles, blood vessels and nerves that supply them, which are caused by the conventional traditional open surgery technique. Many studies have shown that the traditional open posterior spinal fusion approach can be technically successful since X-rays show good results, but the results in terms of symptoms may be poorer than expected. The main symptoms of “Vertebral disease” are persistent back pain, the decrease in the strength of the back muscles and a feeling of fatigue or a heavy feeling in the back after performing activities. Therefore, if extensive incisions are avoided, this problem can be prevented.

Some patients who suffer from pain in the spine undergo all the necessary clinical and imaging tests (x-rays, magnetic resonance imaging, etc.) but no obvious cause of their pain is found. In order for these patients to be relieved, more specialized diagnostic and at the same time therapeutic mild invasive operations may be needed. For example nerve block, intervertebral disc herniation, joint vein denervation. All these methods are examples of minimally invasive treatments of the spine. Most of them are done using ultrasound and do not require hospitalization.

In the past, these patients would either not receive any invasive treatment and would suffer from consuming large amounts of drugs, with whatever morbidity and increase in medical costs this may cause, or they would undergo open surgery, with questionable end results and high costs.

All open vertebrae can be replaced by percutaneous, with the mere exception of surgeries to repair scoliosis. The time of full functional recovery is dramatically reduced by reducing the cost of health expenses.

Microdiscectomy becomes a matter of day care, while the incision in the skin is only 1.5 cm. The patients do not even have to spend the night in the hospital. Thus,recovery is accelated and they are able to return to their activities.

Kyphoplasty for the repair of vertebral fractures (e.g. from osteoporosis), is also done with daily hospitalization and immediate mobilization and relief of the patient.

Of course, we must be very careful in choosing the right methods. There is a risk that patients who need a normal discectomy (even in a minimally invasive way) to undergo, for example, a percutaneous disc coagulation operation, which will offer them nothing and will not avoid the discectomy. Patients are often seduced by attractive terminology (laser, robotics, bloodless, etc.). Not all cases of slipped disc are the same. Choosing the right method reduces the overall cost and inconvenience of a patient. Therefore, if minimally invasive methods are not used properly, they can harm the patient, delaying proper treatment.

Examples of Minimally Invasive Spine Surgery

Surgery

Duration of Hospitalization

Blood loss

Postoperative chronic pain

Type of Anesthesia

Duration of Intervention

Kyphoplasty 1 Day 10-15 cc 1-2 days Intoxication 30-60’
Endoscopic Microdiscectomy Daily 20-30 cc 1-2 Days total 60’
Nerve block Not required 0 0 Local 20’
Joint Denervation Not required 0 0 Local / Intoxication 20 ‘
Minimally Invasive Decompression 1 Day 20-40 cc 1-2 days Total 60-80 ‘
Percutaneous Spinal Cord 2-3 days 40-60 cc 2-3 days Total 40 ‘/ level
Average <1 day 25
cc
1-2
days
45 ‘

Comparison with Classical Invasive Methods

Surgery

Duration of Hospitalization

Blood loss

Postoperative Pain

Type of Anesthesia

Duration of the operation

Laminectomy 3-4 days 100-150 cc 7 days total 60-70 ‘
Microdiscectomy 1-2 days 150 cc 2-3 Days total 60′-90 ‘
Trimetectomy 2-3 days 200 cc 2-4 days total 60′-90 ‘
Open Spine 5 days 400-600 cc 7-10 days Total 60 ‘/ level
Average 3 days 250
cc
5, 2 5
days
75 ‘

 

Proper information of our patients contributes significantly to the selection of appropriate treatment. As surgeons, with respect to international clinical experience, we are constantly updating our techniques. Thus we harmonize with the rapidly evolving methods that improve the health of all, reducing the material and ethical costs of invasive treatment.

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