Spine Technology. Is that all we Need?
I started my practice in 1993. Since that time, there have been significant technologic changes in medicine. Spine Technology has experience significant advances.
The whole medical experience has changed. I think for the most part better, but some will argue differently. In the 1970’s-1980’s, patients were routinely admitted to the hospital for very simple procedures. Patients would spend 5 days in the hospital for a routine carpal tunnel release.
Now, in some outpatient surgery centers, patients are in the facility by 6:30 am, and discharged by 9:30 am. Patients were routinely admitted to the hospital to have diagnostic testing. Now, most go to a diagnostic center to obtain an outpatient MRI, CT scan, or other tests. Major surgeries required prolonged admissions, often for a week or more. Now, patients are discharged within a few days, but have visiting home health services.
In the area of spine surgery, there has been significant improvements in fusion rates, and diagnostic protocols.
Clearly, the addition of metallic instrumentation improved the rates of fusion for lower back surgery. At one time, use of pedicle instrumentation (metallic screws) was very controversial. I can remember the news media demonizing this technique. But now, it is an accepted technique for spinal fusion, and has been shown to improve fusion rates in certain situations. This technological change has improved certain situations.
Likewise, we have better abilities to visualize anatomy compared to the past. We now take MRI technology for granted. But in the past, it was difficult to image problems like disk herniations without subjecting the patients to a painful procedure. We have since evolved from the days of the painful oil based myelogram dyes. MRI techniques show the anatomy with great detail. With the proper strength magnet, and technique, most spine related anatomy is well visualized, with minor discomfort to the patient. Claustrophobia aside, there is little risk with having an MRI test.
As far as surgical options, surgeons are getting better and better with minimal access, and outpatient oriented spine surgery techniques. For the right patient, with the right anatomical problem, the surgery can be performed successfully, with rapid recovery.
Additionally, there are newer spine instrumentation and hardware, including minimal access fusion products, artificial disk replacements, and percutaneous decompression techniques.
But, and there is always a but, utilizing all this technology still is secondary to the following principles:
1. Has the patient had a proper diagnosis? As many of you know, MRI’s and other diagnostic testings are almost too good. Often times, tests demonstrate the natural wear and tear process. Often times, this wear and tear is completely asymptomatic, or non-painful. Is the source of the pain really identified by the testing?
2. Has the patient had adequate attempt at non-surgical resolution? Have you given options such as medications, therapy, injections, and activities modifications a try? In certain instances, emergent surgery is your only option. If you have loss of the ability to use your muscles secondary to paralysis, lose bowel, or bladder control, or have progressive pain, infection or cancer, you may not have any other choice. However, if you do not have a limb or life threatening problem, most patients will try non-surgical options first.
3. Are the goals of the surgery obtainable by the intervention? If you have nerve compression, the goal of the surgery should be to relieve the pressure on the nerve. If you have an unstable spine segment, the goal should be to stabilize or fuse that segment. The surgery, whether using the newer technology or not, should be directed to achieve the goal.
4. Does the patient have the ability to tolerate the surgery? Unfortunately, some patients have other issues besides the spine. If there are significant medical problems such as heart disease, diabetes, obesity, infections, etc, surgery may not be the best option. You need an evaluation by your other physicians, if there are concerns about the ability to survive the surgery.
Technology has definitely improved the recovery period, and outcomes for certain procedures. But in the end, you must be the proper patient for these techniques. Each patient is unique. Each surgery will have its nuances. Please discuss these issues with the surgeon before pursuing surgery.
- Matsukawa K, Yato Y, Hynes RA, Imabayashi H, Hosogane N, Yoshihara Y, Asazuma T, Nemoto K. Comparison of Pedicle Screw Fixation Strength Among Different Transpedicular Trajectories: A Finite Element Study. Clin Spine Surg. 2017 Aug;30(7):301-307. PubMed PMID: 28746125
- Cui GY, Tian W, He D, Xing YG, Liu B, Yuan Q, Wang YQ, Sun YQ. [Effects of robot-assisted minimally invasive transforaminal lumbar interbody fusion and traditional open surgery in the treatment of lumbar spondylolisthesis]. Zhonghua Wai Ke Za Zhi. 2017 Jul 1;55(7):543-548. PubMed PMID: 28655085