Dr. Robert Uteg: Diagnosing and Treating Cervical Spine PainWritten by Laura Miller | January 20, 2012
Robert Uteg, MD, a neurosurgeon at The Bonati Spine Institute in Hudson, Fla., discusses diagnosing and treating degenerative cervical spine conditions with minimally invasive surgery.
Making the diagnosis
At The Bonati Spine Institute, surgeons treat patients with degenerative conditions of the cervical spine, including disc herniations, foraminal stenosis and canal stenosis. Specific treatments the physicians are able to treat with minimally invasive surgery, including their patented procedure, known as The Bonati Spine Procedure, include:
• Disc abnormalities
• Facet joint abnormalities
• Hypertrophy of the ligamentum flavum
The etiology for these conditions can be traced back to several forces, including:
• Cumulative repeated micro and macro trauma
• Genetic predisposition
• Cigarette smoking
The clinical solutions for cervical spine pain include nerve root compression, spinal cord myelopathy and pathology in the facet joint. "Nerve roots are observed as shooting pain, which is distant from the point of origin," says Dr. Uteg. "Spinal cord compression can be acute or chronic and in chronic cases, the spinal cord is pinched by stenosis from bone formation, thickened ligamentum flavum and disc herniation. However, it's more common that pain symptoms arise from facet disease. Facet disease can cause pain or parasthesia in the head, neck and shoulders without evidence of a neurological deficit or nerve root pain. When patients present without these symptoms, but still have neck pain, they may be suffering from facet disease. With facet disease, the pain is local, not radiating."
Locating the pain
Most surgeons use imaging studies, such as MRIs, to diagnose neck pain — but those images don't always reveal the real source of a patient's discomfort. "There are MRIs that accommodate people sitting and standing, but they still don't show hyper-mobility in the spine that might be present as a result of an old facet fracture or stretch injury of the ligaments," says Dr. Uteg. "I also think MRIs sometimes underestimate the thickness of the ligamentum flavum. It may look like there is room around the spinal cord and nerve root, but when we open up the lamina we observe compression of the spinal cord or nerve root by a thickened ligament over the spinal cord and nerve root."
If this is the case, Dr. Uteg explains that ligament removal readily accomplishes decompression of the root and or spinal cord. Since it is difficult to pinpoint the source of pain in some patients, surgeons often employ numerous diagnostic modalities. The physicians at The Bonati Spine Institute ask patients to identify the area where they are feeling pain and then correlate it to a radiographic abnormality of that area. Others may have X-rays that look normal but pain that persists for months or years.
"When patients are consistent about reporting their pain but have 'normal' X-rays, I think we are likely to find a crack in their facet, pressing against the nerve when the patient moves their head and neck," he says. "There is the example of a fractured facet, which isn't clearly seen on an MRI or X-ray. But, being able to glean from their pain history and reporting of where the pain should be, we can go in and remove the fractured portion of the facet or thickened ligament and be confident that we are removing the pain source."
Easing the pain
At The Bonati Spine Institute, the surgeons use a minimally invasive surgical technique and awake anesthesia with patients suffering from degenerative cervical spine disorders. "Awake anesthesia offers several advantages and is one of the principal ways we are able to get instant and reliable feedback from patients on the operating table," says Dr. Uteg. "We ask the patient to move about on the operating table to verify the pain is alleviated when we think we are done with the surgery. Responsive patients tell us when their nerve is adequately decompressed."
After the pain is localized and anesthetic administered, the surgeons place a small tube into that spot, followed by successively larger titanium tubes to dilate the track where they wish to work. "The great advantage of using dilating tubes is we minimize disruption of the anatomical structures," he explains. "We believe that smaller incisions and using the tubes results in less postoperative pain, shorter rehabilitation and recovery times."
The surgeons at The Bonati Spine Institute use a holmium laser with a 4,000 degrees Centigrade tip to vaporize pain fibers in the facet joint. However, if the pain is truly a nerve root compression, the surgeons work to decompress the nerve with a laminectomy and foraminotomy, and possibly also a discectomy.
After the procedure is finished, the surgeons ask their patients to perform an action that was painful before. If they are able to move pain-free, they know the problem has been fixed.
Related Articles on Spine Surgery:
Nerve Transplant for Paraplegic Patients After Spinal Cord Injury: Q&A With Dr. Andrew Elkwood
Spine Surgeons: Is an ACO in Your Future?
8 Statistics on Spine & Neurosurgeon Compensation by Medical Revenue
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