Artificial Disc Replacement

Degenerative disease of the spine is one of the leading causes of disability in the adult population. Most of these patients are treated non-surgically with analgesia, physiotherapy and injections. The majority will get better without surgery. However, a group of patients will
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continue to experience pain. The chronic nature of spinal pain can be disabling and interferes with the ability to work and participate in regular daily activities. For these patients, surgical treatment becomes necessary.

Surgical treatment for degenerative spine disease has traditionally been spinal fusion. Unfortunately, there are a number of drawbacks to spinal fusion. Firstly, the bone may not be able to heal or fuse. The average success rate of fusion is approximately 80%. Failure of the bone to fuse may be associated with continued symptoms. Secondly, fusion will cause stiffness

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and decreased motion of the spine. Thirdly, spinal fusion will cause more stress to be transferred to adjacent levels. This increased stress at the adjacent level may cause further degeneration at the adjacent levels which may lead to additional spine surgery.
Artificial disc replacement is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar (lower) or cervical (upper) spine. The procedure is used to treat chronic, severe low back pain and cervical pain resulting from degenerative disc disease.

Artificial disc replacement has been developed as an alternative to spine fusion. The introduction of the total disc replacement aims to relieve patient symptoms while preserving motion at the operative spinal level. The advantage of preserving motion is to minimize the stress at adjacent levels and thereby decrease the risk of degeneration of the adjacent segment.
Currently artificial disc replacement can be used for the lumbar or the cervical spine. Many different models have been developed. The majority consists of two metal plates Prom Dresses that have teeth to anchor the implant onto the bone of the vertebral bodies. Between the two plates is a metal core or a plastic core made up of polyethylene that allows for motion. Figure 1 shows a lumbar artificial disc replacement. Figure 2 shows a cervical artificial disc replacement.

Figure 1. Lumbar artificial disc

Figure 1. Lumbar artificial disc

Figure 2. Cervical artificial disc

Figure 2. Cervical artificial disc

 

 

 

 

 

 

 

 

 

 

The clinical diagnoses for lumbar artificial disc replacement include symptomatic degenerative disc disease and post-discectomy syndrome. Post-discectomy syndrome is persistent back pain following previous surgery to remove a

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herniated disc. For cervical artificial disc replacement, the diagnoses include cervical radiculopathy (where the nerve root is compressed) and cervical myelopathy (where the spinal cord is compressed).

The technique to insert an artificial disc (whether in the neck or low back) is routine and safe. For the cervical spine it involves going from the front of the neck. For the lumbar spine, it involves going through the abdomen. The procedure begins by removing the gelatinous disc between the vertebrae. Once the disc is removed, two metal plates are pressed into the bony endplates above and below the space now vacated by the disc. Metal spikes hold these plates in place on the bone. Eventually bone will grow over and around the metal plates. In between the metal plates is a metal or plastic core made of a polyethylene. Figure 3 shows the artificial disc placed in the spine.

Figure 3. Artificial disc placed in spine

Figure 3. Artificial disc placed in spine

Careful selection of patients for artificial disc replacement is critical. There are several conditions that may prevent patients from receiving a disc replacement. These include spondylolisthesis (the slipping of one vertebral body across a lower one), osteoporosis, vertebral body fracture, allergy to the materials in the device, spinal tumor, spinal infection, morbid obesity, significant changes of the facet joints (joints in the back portion of the spine), pregnancy, chronic steroid use or autoimmune problems. Also, total disc replacements are designed to be implanted from an anterior approach (through the abdomen for lumbar). Patients may be excluded from receiving an artificial disc if they previously had abdominal surgery or if the condition of the blood vessels in front of the spine increases the risk of significant injury during this type of spinal surgery.
In addition to the potential complications associated with general anesthesia, the complications associated with artificial disc replacement may include breakage of the metal plate, dislocation of the implant, infection, nerve injury and injury to blood vessels and urological structures. To help minimize complications associated with the implant itself, proper selection of patients and size of implant is very important. Also, artificial implants may fail over time due to wear of the materials and loosening of the implants.

Recovery from artificial disc replacement and care afterwards are much like that for other anterior approaches to the spine. In some cases, recovery is faster than for a traditional fusion surgery. There is less pain from the

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procedure and fewer complications in general. Another potential advantage of disc replacement is a more rapid

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return to activities than occurs after fusion surgery. Fusion patients have limited activities during the time required for the bone graft to grow into a solid mass. Because one of the goals of artificial discs is motion, patients are encouraged to return to motion early, although at a gradual progression. The length and type of activity restrictions following surgery are also much less with disc replacement.

Contributing Specialist:

(Spine Surgery)

Island Orthopaedic Consultants
Gleneagles Med Ctr,#02-16,
Tel:(65) 6474 5488, 6479 8998
Mt Elizabeth Med Ctr, #06-03,
Tel:(65) 6737 5683
Website: www.iog.com.sg

 

Treatment of Adolescent Scoliosis

Each case of scoliosis, defined as three-dimensional curvature of the spine, is as unique as the person who has the condition. If the size of the curve is less than 25 degrees in the growing child, periodic observation by us is sufficient. Wearing an orthotic brace is beneficial if the curve reaches 25 degrees or more in a growing child with immature bones. Bracing can come in the form of a traditional TLSO (Boston brace) or dynamic SpineCor brace. The role of physiotherapy or chiropractic manipulation is still controversial. When the curve measures more than 40 to 45 degrees in the growing child, and more than 50 degrees in the skeletally mature patients, surgery may be the best treatment.

Surgical Approaches

Scoliosis surgery aims to arrest the progression of the curve, while at the same time making a curved spine straighter. It

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is important to try to preserve as much of the spine’s natural mobility as possible.

For many patients, scoliosis surgery is done from the back or posterior approach i.e. posterior spinal fusion with instrumentation. Bone is taken from another part of the patient’s body (either local sources, ribs, or the pelvis) and then grafted onto the vertebrae. The bone graft will take at least one year to “harden” to the vertebrae. Nowadays, we routinely take the bone from the ribs so that we can at the same time reduce the rib hump deformity. To stabilize the fusion and hold the vertebrae in place during this time period, two titanium rods are attached to the spine with hooks or pedicle screws or both. For stiff and large curves, we may elect to use cobalt-chromium rods instead, which are stronger than titanium rods.

Sometimes the best approach is from the front, or anterior region. This maybe possible if the patient only presents with one significant curve. In this type of surgery, the incision is made through the chest and/or abdominal cavity. If the curve is in the chest, we may perform thoracoscopic surgery – a type of minimally invasive surgery-to correct scoliosis. This technique is possible because of good images provided by the camera connected to the thoracoscope. This technique results in smaller incisions (four one-half inch incisions on the side of the chest wall compared with one 10-inch incision with traditional front approach, and also avoiding a long scar at the centre of the back compared with the traditional

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posterior spinal fusion and instrumentation). It is particularly suitable for patients who have scoliosis confined to the thoracic spine or where the spine can be reached through the chest cavity. Other requirements include curves which are right sided. In this procedure, the

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patient is placed on her or his side. The right lung is temporarily deflated by the anesthetist for the duration of the surgery. The procedure involves removing the discs between the vertebrae so that the spine becomes “looser”. The spaces are then filled with bone taken from the ribs. Titanium screws will then be inserted under radiographic control. A rod will be used to connect the screws, and by doing so straightens the spinal curve. The picture below illustrates the small incisions used in this form of minimally invasive spine surgery.

There are times when a combined anterior and posterior (from behind) approach is used, if the curve is too big and rigid. Generally, we will first approach the front to “loosen” the spine by removing the discs between the vertebrae. The second stage will

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involve opening the back of the spine, and correcting the scoliosis using a combination of hooks or screws, although the tendency is to use all screws nowadays as they offer better stability than hooks.

Generally speaking, scoliosis surgery requires 4 to 5 hours in the operating room and a hospital stay of about 5 to 7 days. Most patients return to school or work 2 to 4 weeks after surgery; sporting activities can be resumed at about 12 months post-surgery.

The pictures below show the x-rays of a patient who had severe scoliosis before and after surgery.


 

 

 

 

 

 

 

 

 

Neurophysiological Monitoring

One of the risks of scoliosis surgery is injury or damage to nerves contained within the spinal cord. Specifically, though unlikely, there is a chance of paralysis. Traditionally, the patient is awakened during surgery to ensure that the nerves are unharmed and movement is normal. We routinely use neurophysiological or intraoperative nerve monitoring, where wire leads are connected from the patient’s foot or leg to the skull. A technician constantly monitors

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the nerve activity, which is detectable through these leads throughout the operation. We also perform the traditional “wake-up” test if required.

Blood product support

Scoliosis surgery potentially involves significant blood loss. During surgery, blood can be conserved by using meticulous technique and state-of-the-art surgical instruments to stop or prevent excessive bleeding. In many cases, blood lost during a surgical procedure can be salvaged and recycled using cell savers. Certain medications maybe administered by our anesthesiologist to reduce intraoperative bleeding e.g. tranexamic

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acid. Occasionally, we will get the patients to donate their blood before the surgery to be re-transfused back to themselves during or after the surgery (autologous transfusion).

Summary

For surgeries as complex as those used to correct scoliosis, there’s no substitute for an experienced health care team, from the surgeons who specialize in spinal surgery,nurses in the wards, physiotherapists who provide chest physiotherapy and ambulatory physiotherapy. We

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offer scoliosis patients:

  • Comprehensive counseling before and after surgery.
  • A comprehensive approach to the non-operative and operative treatment
  • Availability of highly qualified spine surgeon to perform the surgery
  • The use of high-quality fluoroscopic (X ray) images during surgery
  • Intraoperative nerve monitoring
  • Excellent post-operative care at our paediatric high-dependency and intensive care unit if required

X rays of a patient who had thoracoscopic fusion and instrumentation of thoracic scoliosis

 

 

 

 

 

 

 

 

 

 

 

 

 

Contributing Specialist:

Dr Hee Hwan Tak
MBBS, FRCS (Ed), FRCS (Glas), FAMS (Ortho)
Medical Director and Senior Consultant, Pinnacle Spine & Scoliosis Centre
Mobile: 65-98283132
Tel: 65-67370680
Fax: 65-67370522
Emergency: 65-97718964
Website: http://www.p-ortho.com
3 Mount Elizabeth, Mount Elizabeth Medical Centre, #04-07, Singapore 228510
Adjunct Associate Professor, Nanyang Technological University, Singapore

Panel of Medical Experts, The Subordinate Courts of Singapore

Associate Editorial Board Member, The Spine Journal (USA)

 

Facts about Adolescent Scoliosis

Adolescent Scoliosis is a structural three dimensional curvature (C or S shaped) of the spine that occurs at or near the onset of puberty for which no cause has

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officially been proven. Special Occasion Dresses Studies have been done for different probable causes (genetic, brainstem control, hormones such as growth hormone and melatonin) but no firm conclusion was made. There is no evidence to suggest any association with diet, bone density, back posture, or heavy school bags in the causation of the scoliosis. Scoliosis shows up in teenagers

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from ages 10 to 14, and girls over the age of nine are five times more likely to get scoliosis than boys of the same age.

 

Scoliosis can cause a shortened stature when untreated. Curves more than 80 to 90 degrees are associated with shortness of breath and risks of heart failure and death. Patients with this degree of scoliosis will also have more concern about their cosmetic appearance. The association of pain is controversial still, with some studies showing little difference as compared with normal population, while others reported significant

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increase in back pain with increasing severity of the scoliosis.

 

Examination is done using Adams test,

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where the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily observe for any asymmetry of the trunk or any abnormal spinal curvatures. Treatment varies from non-operative (bracing)
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to operative (surgical correction), which aims to keep the patient’s curvature from progressing beyond the important threshold of 50 degrees at maturity. This threshold is important, because once the scoliosis exceeds 50 degrees, there is tendency to increase well beyond adulthood.

 

For mild cases, the patients require check-ups every 6 to 12 months. Moderate cases will be advised to wear a brace. The standard brace is a Boston brace, although a dynamic brace (SpineCor) maybe an alternative. Studies have shown that full-time bracing is significantly more effective than part-time bracing in the control of scoliosis. Surgical treatment is indicated in scoliosis of more than 40 degrees in a growing child, and in anyone which has scoliosis of more than 50 degrees. Surgery will fuse the affected spinal bones (vertebrae) in a more normal balanced position, and allow remaining growth to proceed normally in the other parts of the spine.

 

Different surgical approaches (from the back or the front) can be done depending on the characteristics of the scoliosis. Surgery in our institution is accompanied by spinal cord and nerve monitoring which greatly increase the safety of the surgery. Spinal surgery with modern instrumentation significantly corrects the spinal deformity and stops the curve progression. Minimal access technology used in some selected scoliosis cases will allow for improved scar healing with similar outcome. Patients are usually out of hospital in five to six days and back at school in two to three weeks. They are advised to refrain from excessive bending and heavy lifting for three to four months. They can swim after six months, and participate in athletics after 12 months.

In summary, adolescent scoliosis is a progressive curvature of the spine of unknown cause. Treatment will depend on the severity of the curve, and it is important to start treatment early before the scoliosis worsens. Early intervention will ensure a better outcome.

Contributing Specialist:

Dr Hee Hwan Tak
MBBS, FRCS (Ed), FRCS (Glas), FAMS (Ortho)
Medical Director and Senior Consultant, Pinnacle Spine & Scoliosis Centre
Mobile: 65-98283132
Tel: 65-67370680
Fax: 65-67370522
Emergency: 65-97718964
Website: http://www.p-ortho.com
3 Mount Elizabeth, Mount Elizabeth Medical Centre, #04-07, Singapore 228510
Adjunct Associate Professor, Nanyang Technological University, Singapore
Panel of Medical Experts, The Subordinate Courts of Singapore
Associate Editorial Board Member, The Spine Journal (USA)

 



Minimally Invasive Spine Surgery

Introduction

Traditional spine surgery usually requires long incisions. Muscles are cut and moved away from the spine to expose the surgical area. This causes increased pain, long recovery time and impaired spinal function.

With minimally invasive (keyhole) techniques, surgery on the spine can be performed with a wound of only 2-3cm and many of these can be performed as day surgery. Prolapsed intervertebral disc, spinal stenosis and spondylolisthesis are some of the conditions that can be performed with minimally invasive surgery.

Technique

In minimally invasive surgery a tubular retractor is used to dilate the muscles and create a tunnel to expose the spine (Fig 1a,b). Using the tubular retractor, procedures to relieve pressure on the spinal cord and to remove the slipped disc can be performed.

In patients who require spinal fusion to stabilize the spine, the metal screws and rods can be inserted through small wounds (Fig. 2).

Advantages

1. Smaller scars

2. Less tissue trauma

3. Less blood loss

4. Less postoperative pain

5. Shorter hospital stay

6. Faster rehabilitation

7. Quicker return to work and normal activities

Clinical example

70 year old

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patient with back pain and both leg pain which is worse with walking. Patient underwent minimally invasive surgery to relieve the pressure on the spinal nerves. He had rapid recovery with a small wound.

References

  1. Benedict Peng. Clinical and Radiological Outcomes of Minimally Invasive versus Open Transforaminal Lumbar Interbody FusionSpine 2009 Jun 1;34(13):1385-9.

Contributing Specialist:

(Spine Surgery)

Island Orthopaedic Consultants
Gleneagles Med Ctr,#02-16,
Tel:(65) 6474 5488, 6479 8998
Mt Elizabeth Med Ctr, #06-03,
Tel:(65) 6737 5683
Website: www.iog.com.sg

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What Can You Do To Help Your Back and/or Neck?

In our fast-paced society, we often look for “quick fix” solutions to quickly remove the pain. We need to understand that in many instances, back or neck pain become obvious as a result of years of “neglect” of the spine. Patients with back or neck pain can become sedentary, or become out of shape, gaining weight that places more strain on the low back. Our goal at the Centre for Spine and Scoliosis Surgery (CSS) is to make your back or neck stronger, more flexible, and thus reducing the chance of further injury. Many of these can be achieved by educating you on the structure and function of the spine, and the lifestyle modifications that may accompany.

While a spinal injection or surgery can help relieve symptoms, not maintaining spinal muscle strength and flexibility, or use of good body mechanics can increase your likelihood of future problems. You have to remember that as you get older,

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especially past the age of 40, the back is more prone to injury. You may need to avoid lifting heavy objects, or participating in contact sports involving twisting, bending, and jumping, because these activities can damage your back or neck.

Ergonomics is important, and it means matching the

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sure your chair molds properly to your back. If you are too short or too tall for your back to rest properly in your chair, or if your company does not offer ergonomically designed chairs, consider bringing in a rolled-up towel. Place it behind your low back to reduce the amount of stress on the back. While sitting, make sure your feet rest flat on the floor. If this is a problem, use a footstool. Proper foot and leg alignment will ease back stress. While typing on a computer, your forearms and thighs should be parallel to ensure proper shoulder alignment. If necessary, use a pad to support your wrists while typing. The monitor should be at eye-level or slightly below eye-level. Last but not least, always get up and move around every half hour, even if it is just a quick stretch by the side of your desk.

Some jobs require standing for many hours at a stretch. People rarely distribute their weight equally onto both legs while standing. They tend to shift their weight from one side to another, throwing the spine out of

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alignment, which can lead to back strain.

If you have difficulty standing without shifting weight, try standing with one leg on a footrest, periodically switching feet. It is also important to do back stretches now and

then in order to reduce stiffness of the back.

Lifting is a common activity in our daily life. When lifting, maneuver the object close to your body, and use the strength in your legs to get the object off the ground, rather than your low back. Whenever possible, your back should not bend forward when lifting something, however light it may appear.
Contributing Specialist:

Dr Hee Hwan Tak
MBBS, FRCS (Ed), FRCS (Glas), FAMS (Ortho)
Medical Director and Senior Consultant, Pinnacle Spine & Scoliosis Centre
Mobile: 65-98283132
Tel: 65-67370680
Fax: 65-67370522
Emergency: 65-97718964
Website: http://www.p-ortho.com
3 Mount Elizabeth, Mount Elizabeth Medical Centre, #04-07, Singapore 228510
Adjunct Associate Professor, Nanyang Technological University, Singapore
Panel of Medical Experts, The Subordinate Courts of Singapore

Associate Editorial Board Member, The Spine Journal (USA)

 

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