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Motion Preserving Spine Surgery

There are times when a fusion is recommended to treat an issue with spinal instability, or when the surgery to decompress nerves removes bone that will then result in instability.  But there are implications of performing spinal fusion - namely the stresses that the other levels on the spine feels increased after a fusion, and this can lead to an increased rate of needing further spine surgery in the future.  So if you have been recommended a spinal fusion, it's good to ask a few questions:

  • Why do I need a fusion?

  • Are there any non-fusion alternatives?

In many cases, non-fusion decompression options are available, such as diskectomy or laminectomy.  In some cases where fusion is traditionally utilized, there are non-fusion alternatives such as cervical or lumbar disk replacement, or posterior arthroplasty options such as the TOPS procedure.  Dr. Wind has incorporated all of these surgical procedures into his practice with a goal of offering patients all of the options of minimally invasive and motion preservation surgery for their spinal conditions.

Cervical Disk Replacement

Cervical disk replacement

There are multiple surgical options for patients with neck or cervical spine disorders.  Some of these classical operations include non-fusion options, but one of the most common and most successful options for surgical treatment in the cervical spine is anterior cervical diskectomy and fusion (ACDF).  This includes approaching the spine from the front of the neck, removing the diseased disk as well as bone spurs, and then inserting bone or a synthetic spacer to allow bony healing to occur - turning what used to be 2 separate bones into 1.  A plate and screws are often used to increased the chance of healing and to avoid the need for wearing a hard cervical collar after surgery. The outcomes of ACDF are excellent, and it is a tried and true option for many patients.  However there is increasing understanding and literature basis to suggest that fusing bones in the cervical spine has a negative impact on the other levels of the spine, and that this change in the spine's motion may lead to increased breakdown in the levels next to the fusion.  This may lead to future symptoms, as well as the need for further surgery.  The risk of this is not trivial, and reaches as high as 25% of patients by 10 years after their ACDF procedures.​ With this knowledge, there has been significant advancement within industry and the spinal surgery community to develop non-fusion alternatives, with a goal of maintaining normal biomechanics and avoiding the problems that may occur following fusion.  This has led to the development of cervical disk replacement, or cervical arthroplasty.  The first FDA approved cervical disk replacement became available in the early 2000s, and since this time there are now multiple cervical artificial disk implants available, with increasing long-term clinical data to support their use. Cervical disk replacement (also known as arthroplasty) has shown itself to be equivalent to ACDF in terms of patient outcomes, with a decreased rate of needing further surgery at the adjacent levels. These procedures (like most ACDFs) are performed either outpatient (going home the same day) or the next day after surgery.

Lumbar Disk Replacement

Lumbar disk replacement

Lumbar disk disease resulting in low back pain is largely treated with non-operative treatment strategies, or with fusion surgery.  The goal of the fusion surgery is to remove the motion of the diseased spinal segment, halting the generation of pain related to the malfunctioning disk.  Lumbar disk replacement alters this paradigm, seeking to replace the malfunctioning disk and its associated pain with an implant that maintains motion.  This has benefits of maintaining a more natural biomechanical function of the lumbar spine, as well as seeking to avoid the shifting of these biomechanical forces to the adjacent levels of the spine, similarly to the discussion of adjacent segment disease in the cervical disk replacement discussion above. The first lumbar disk replacement gained FDA approval for use in the US in 2004, and since this time there have been further prosthetic disk implants developed with a goal of maintaining motion and alleviating pain in lumbar degenerative disk disease. ​Lumbar disk replacement involves approaching the lumbar spine from the front (through the abdomen).  A vascular surgeon helps access the spine, where the entire disk is removed.  Following removal, the disk replacement implant is selected based upon size and fit of the patient, and is then inserted using x-ray or 3D navigational assistance.  The abdominal incision is then closed. This procedure is performed in usually 2-3 hours, and is accompanied with an average of 1-night stay in the hospital.  Patients are encouraged to get up and walk around the same day as surgery. In contrast to cervical disk replacement, there is less robust long-term data analyzing lumbar disk replacement.  The initial clinical trials analyzing lumbar disk replacement described clinical outcomes at 24 months.  A primary goal of lumbar disk replacement is to maintain normal biomechanical motion and avoiding adjacent segment disease and further surgical treatment.  5 year clinical data from 1-level lumbar disk replacements demonstrated maintained motion of the disk replacements, and 1/3 the rate of surgery for adjacent segment disease compared with the patients treated with fusion.

TOPS Procedure

TOPS posterior facet arthroplasty replacement

For patients with stenosis (compression of the nerves) and spondylolisthesis (a slipped vertebra), back and leg pain symptoms may require surgical treatment.  And current data suggests that decompression and fusion is superior to decompression alone, in terms of avoiding future surgeries and improving outcomes.  Fusion technologies and minimally invasive techniques have increased the success and patient outcomes associated with these procedures, but fusion by its definition alters the biomechanics of a normal spinal motion segment. ​The TOPS procedure is a procedure and implant seeking to address this specific patient population, those needing decompression of the nerves but wanting an alternative to fusion for their spondylolisthesis.  The TOPS device is a surgical implant that allows motion of the spine following decompression, while keeping the spondylolisthesis from worsening. Dr. Wind was a principal investigator in the FDA-IDE study which documented positive clinical outcomes and superiority to fusion in some measures, leading to FDA approval of the TOPS device. Dr. Wind now offers this to patients as another option for motion preserving lumbar spine surgery.

If you are looking for an alternative to fusion, or to have a discussion about the pro's and con's of fusion or a motion preserving spine surgery, Dr. Wind can offer a comprehensive discussion regarding all of these techniques.  This comprehensive approach allows Dr. Wind to tailor surgical solutions to each patient based upon their spinal conditions, their symptoms, and their individual goals.

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