It is remarkable, but true, that most people seem to spend a great deal more time in selecting downloads for their iPods and iPhones than in selecting a spine surgeon. This is unfortunate because it is an important decision which often dictates a patient’s long-term quality of life.
Medicine is a profession, as many others, where prevailing therapeutic approaches may be, in fact outdated. There was a time, not too long ago when diseased hips, knees and ankles were routinely fused. Then the era of artificial joints changed this previously universal approach.
Spine surgery is still being held hostage to the “fusion” mind set. The spine is inherently flexible and forcing it to become rigid, particularly over many segments, continues to be the cause of significant stress related spinal problems. The result of this is the inordinate and continuing production of “failed back surgery syndrome” patients.
It should seem readily evident that the architects who design skyscrapers endeavor to include some flexibility in case of external stress such as hurricanes or earthquakes. If they do not do so these structures will collapse under such circumstances. The same is true
of the human lumbar spine and this is an important part of the concept of restorative spine surgery.
The need to reduce spine surgery failure has led to the advent of more physiologic, motion preserving, spine technologies of which artificial discs have probably received more than their fair share of M2H attention. It continues to be a sad, but true, story that some of the very best treatments often are associated with less commercial profit expectations and thus become medical “orphans” ignorant of William of Occams’ Razor. Flexible stabilization systems and artificial disc nuclei exist today as well as restorative neuroradiology where polymers are injected.
It is essential for patients to become aware of all valuable options and search out those associated with less risk and higher efficacy. In spine surgery motion-preserving reconstructive (restorative) spine surgery represents one such important choice.
It is not surprising that surgical reconstruction in breast surgery, facial surgery, and long bone surgery is well known by the public. Few patients, however, appreciate that these same principles of restoration can also apply to spine surgery.
Reconstructive spine surgery focuses on the rebuilding of a spine by utilizing the patient’s own tissues and less hardware. Autogenous (patient’s own) bone, bone marrow and other tissues are used for this transformation. Restorative surgery is typically performed on patients who have progressive neurologic impairment (not just back pain for which non-surgical therapy is usually sufficient). The primary need of these patients is to decompress the involved nerves as the most important part of the surgery. When stabilization is also required, advanced standalone interbody biomechanical devices characterized by self-tapping titanium cages are used in place of rigid fixation instrumentation.
The use of a patient’s own tissues for spine reconstruction (as opposed to donor bone tissue) is well established in medical practice but is often not considered because it involves more effort on the part of the surgeon. The milestones for use of cost-effective autogenous tissue have been:
- The “feathered fusion” developed byHibbs in 1911.
- Free fat transplants first performed by Lexer in 1919.
- Bone marrow aspirate first being used as the source of stem cells by French physicians in the late 1950s and by spine surgeons at this time in place of expensive bone morphogenic protein (BMP).
RESTORATIVE SPINE SURGERY
Reconstructive (Restorative) spine surgery is of particular value in treating patients afflicted with multi-level degenerative problems, particularly those due to underlying genetic (genomic) spine disease in which neurologic impairment has occurred. It is also of great value in salvaging “failed back surgery syndrome” patients.
In addition to demonstrating higher levels of both safety and efficacy Restorative Spine Surgery also allows significant reductions in surgical cost and post-operative complications. Why then is it not practiced more? The following are the key reasons:
- Few spine surgeons have the training and experience to perform it.
- The majority of spine surgeons are not expert at adequate nerve decompression.
- Rigid “fusion” with screws and rods requires only mechanical skills and has been very rewarding financially to surgeons. Because of this rigid multi-level instrumented fusion is not infrequently used as a primary treatment for low back pain.
- Few patients are sufficiently well enough informed to pose these important questions prior to surgery (but this is changing).
A serious impediment to reconstruction has been the word “fusion” (used to denote rigid fixation) which has been used to describe all forms of surgical stabilization while ignoring more advanced “non-fusion” technologies. The American Medical Association no longer uses the term “fusion”; in it’s Current Procedural Coding Handbook (2004) the word “fusion” has been replaced by the term “arthrodesis” (Gk: arthro-joint; desis-to bind). Arthrodesis is clearly a better expression to describe the various forms of spine stabilization ranging from flexible to rigid.
Examples of other non-rigid surgical spine technologies are flexible stabilization device systems which include artificial discs (arthroplasty), including prosthetic discs and nuclear implants as well as intra-discal polymer installations.
It should be the ethic of all spine surgeons to assist the body to return to more normal function and to endeavor to avoid creating more patient problems than there were to start with.
A good first step for patients requiring the services of a qualified spine surgeon would be to become a well informed health care consumer so that the right questions can be asked. The next step would be to go to the web site of the American Board of Spine Surgery and find the name and address of the nearest Diplomate. At this point in time making inquiries of Operating Room personnel at this surgeon’s hospital regarding their abilities would be prudent on the part of the patient.