From complex cases on patients with comorbidities to how novel spine surgery protocols or techniques helped achieve a positive outcome, nine spine surgeons from health systems and private practices around the country detail the surgeries of which they are most proud.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
Next week's question: What spine surgical skill, technique or technology do you wish to learn or master in the next five years?
Please send responses to Alan Condon at acondon@beckershealthcare.com by 5 p.m. CDT Wednesday, Sept. 7.
Editor's note: Responses were lightly edited for clarity and length.
Question: Next week's question: Can you detail a recent spine surgery that you are particularly proud of? What was challenging about the patient's condition? How did you approach the surgery and what was the outcome?
Peter Derman, MD. Texas Back Institute (Plano): A young man in his twenties came to me with pain radiating down his lower extremity and a partial foot drop due to a foraminal disc herniation at L5-S1. Symptoms persisted despite attempted conservative care. He was told by two other surgeons that accessing the herniation and decompressing the nerve would necessitate fusion. He was understandably hesitant to undergo such an operation, so he came to me for another opinion. I reviewed the imaging, which revealed that he indeed had a narrow pelvis; this would have been an impediment to an isolated decompression if performed via open or even tubular techniques.
However, there was enough of a corridor to access the herniation endoscopically. I performed an outside-in endoscopic foraminal discectomy on him, which went smoothly. He had complete resolution of his pain and weakness, took no narcotics after surgery and had essentially zero downtime. Importantly, this young patient was able to avoid a fusion surgery and the risk of future adjacent segment issues.
I never cease to be amazed by how quickly patients bounce back after endoscopic spine surgery. Smaller incisions, minimal muscle disruption and less (if any) bone resection allow for rapid recovery. However, spinal endoscopy really shines in cases like this in which it fundamentally changes the operation I am able to offer and allows patients to avoid fusion altogether.
Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): About seven years ago I had a patient who came to me and needed a spinal fusion. She previously had shoulder surgery under general anesthesia and was scared of undergoing surgery due to the effects of general anesthesia on her body. At that time, I discussed the awake spine surgery protocol that we developed and how she would be a perfect candidate to undergo an awake spinal fusion.
As she was a widow with a daughter who lived more than an hour away, she was very worried about the post-operative recovery, especially because she would be by herself. When we discussed the benefits of the awake spinal fusion procedure, including reduced likelihood to develop delirium or confusion after surgery, she enthusiastically signed up for the surgery.
We performed an L4-5 awake spinal fusion on her. She did incredibly well and experienced minimal pain after surgery. She was able to regain her independence soon after and was happy that she avoided general anesthesia. Ever since then, we have continually evolved and improved our awake spine surgery protocol. This patient's story was the birth of our awake spinal fusion program.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: About a year ago, I saw a patient who had an isthmic spondylolysis repair about 5 years previous using only posterior pedicle screws. Initially, she did well but developed a progressive slip at the level above and a pseudoarthrosis at the index level. It was required to perform a posterior-anterior-posterior revision. I was pretty nervous about drilling out the facets at the index level and getting the level mobilized enough to be able to then do a two-level anterior interbody fusion and then finally reduce her slips from behind. She is almost 8 months out, fused great and is walking upright and off all meds, including gabapentin.
Jeremy Smith, MD. Hoag Orthopedic Institute (Irvine, Calif.): One of my patients is an active firefighter in his 30s who had severe thoracic level pain and was bounced around to multiple medical providers and had several visits to the emergency room. He had no neurologic concerns and the symptoms were vague. A colleague who is a family friend referred him to me. A simple X-ray saw a unilateral absent pedicle in the mid-thoracic spine. An MRI scan we obtained found a large infiltrative lesion occupying two vertebra causing severe spinal cord compression with myelomalacia. The CT scan showed erosions and a pending fracture. His fate seemed ominous. I performed a lateral vertebrectomy with expandable cage at two levels and a posterior instrumented fusion. The pathology report came back metastatic melanoma. After surgery and a year of immunotherapy, he is in full remission and back to work as a firefighter. I see him every year and when I do it reminds me why we do this job.
Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): A recent spine surgery I am particularly proud of was my resection of an intradural extramedullary spinal tumor. The patient had suffered from debilitating weakness in his legs for almost 6 months before he visited the hospital. On physical exam, he had a marked sensory level and only muscle contraction — but no active movement — of his lower extremities, even with gravity eliminated. After proper radiographic workup identifying the tumor, gross total resection was performed the next day. One week later, the patient was ambulating independently.
Sometimes the challenge is not something we can control. For example, the challenge in this case was the patient waiting to present until the symptoms were so severe, making the outcome after surgery less predictable. The surgical approach was not a concern or challenge in this surgery (laminectomy, dural opening, coring of tumor for decompression, then working around it for complete resection). The concern is how can we as spine surgeons do the best we can for a patient regardless of the given circumstance/condition in which a patient presents.
This surgery was particularly gratifying because it highlights the degree of impact we can have on a patient's life. "Impact" is why I love spine surgery and the ability to help people return to functionality. I think spinal tumors is also an important differentiating qualification of neurosurgeons compared to orthopedic spine surgeons which brings a sense of pride as well.
Chester Donnally, MD. Texas Spine Consultants (Addison): Recently, I featured the 6-month follow-ups on my various media platforms showing a patient in his 50s with kyphoscoliosis in the setting of neurofibromatosis type one. The required three-level corpectomy and management of the neurofibromas of the anterior cervical spine. There were probably 10 things that could have gone wrong. I am extremely fortunate to be in a spine group in Dallas that has some experts in cervical spine surgery, so I invited my friend and senior partner Dr. Andrew Park to join me on this all day case. I am proud that this patient did fantastic. He legitimately is a living billboard for me in many social media forums. I am proud that my own digital marketing resulted in a med school colleague sending me this opportunity, as opposed to her in-house spine surgeons. And I'm proud I have enough self-recognition to ask for help when doing certain surgeries.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): I am proud of any surgery where I get to improve a patient's quality of life and return them to full function. A recent example was a man who presented with lumbar stenosis and instability due to adjacent segment degeneration above prior fusion surgery. The original procedure was done in traditional "open" fashion that created a lot of scar tissue and prolonged recovery.
Using minimally invasive techniques, including computer navigation and robotic assistance, I was able to remove the old hardware and perform minimally invasive lateral fusion and decompression at the adjacent segment through very small incisions in single position with minimal blood loss while avoiding most of the prior scar tissue. The patient felt immediate improvement in his back and leg pain and went home the next day. He was off pain medications within days and returned to full function 3 months after surgery — much faster than with traditional "open" spinal fusions.
Francisco Espinosa-Becerra, MD. NorthShore Neurological Institute (Arlington Heights, Ill.): I had a patient in his 30s with four disc herniations and spinal cord compression. He was not able to walk. I performed a three-level discectomy and fusion at C4-5, C5-6 and C6-7, and an arthroplasty at C3-4. I had a clinic visit with him after the operation and he is experiencing excellent outcomes. He is able to walk and does not have any apparent neurological deficits.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): As an employee of a large health system, the predominance of our complex spine caseload is those aged patients with previously failed interventions, precluding comorbidities, bariatric concerns or insufficient sureties. Most community spine surgeons will forgo these cases for all the aforementioned reasons, subsequently leaving a larger pool of complexities for larger healthcare centers that provide this type of service.
Recently, an adult syndromic patient from a rural town presented to our clinic with heterotopic ossification from a previous spine surgery as a child. Ambulating two years previous had now declined into wheelchair-bound paraparesis and familial care issues had escalated. Radiological modalities confirmed the diagnosis of bony overgrowth and severe multilevel lumbar stenosis in both the old and new lumbar levels. In short, a prolonged, belabored decompressive surgery followed, reconstituting and near normalizing the intercanalicular distance was achieved. A microscopic technique utilizing lateral (normal tissue planes) to medial dural detethering was accomplished. Dural compromise was avoided throughout. The patient is currently at home standing with assistance and initiating ambulatory mobility.