Tuesday, May 3, 2022

 Blog Topic: Disc herniation/Bulges in adolescents and how to treat

5-3-2022

 

So, the symptoms of lumbar disc problems and the cause symptoms (pressure against nerve roots) are similar between adults and adolescents. 

What is different?

In adults the pressure is created by a dehydrated (lack of water) or a bad disc herniates through the posterior ligament in adults

In adolescents the growth plate on the vertebral body (called ring apophysis) fractures and pushes backwards.


So what are the available treatments for adolescents? There are two main groups:

·        Nonoperative

o   Rest (short-term only)

o   Analgesics (pain medications)

o   Physiotherapy: Paraspinal and Core strengthening, aerobic conditioning

o   Spinal injections: epidural and selective nerve root

o   What do I not recommend:

§  Chiropractic manipulation

§  Bracing (weakens back and core muscles)

·        Operative/Surgical: Microdiscectomy

 

Some important facts:

+ Nonoperative treatment listed above is almost ALWAYS the first step in care.  This is because most ring apophyseal injuries are minor, heal and don’t cause long-term problems.

+ Persistent numbness and weakness require more urgent treatment and more frequently need early surgery.

+ There is no hurry to do surgery (from a surgeon standpoint) when there is only pain down the leg +/- back pain.  Surgery appears to be helpful in relieving leg pain even if done late.

+ Selective nerve root injections can be diagnostic and therapeutic.  Even temporary symptom improvement is important as it can help identify the cause of the back/leg pain.

+ Microdiscectomies do a good job of improving leg pain, but not a good job of alleviating back pain.

 

When should I consider an Operative/Surgical Microdiscectomy?

If nonoperative treatments have failed to adequately alleviate leg pain

There is a ring apophseal fracture or disc herniation on MRI

Selective Nerve Root Injections confirm pain generator, even if only temporary relief

Discussions with your surgeon determine the pain generator is the disc and no other nonoperative options remain which could help.



Thursday, April 7, 2022

 

Blog Topic: Disc herniation/Bulges in adolescents, and how they differ than those in adults.

4-7-2022

 

When talking about a new topic, I have tended to go into significant detail about the basics of the problem to be discussed.  However, after review of the below webpage from the American Academy of Orthopaedic Surgeons (AAOS) I don’t think I can do a better, more thorough explanation of the anatomy, pathology, diagnosis and treatment of disc herniations in adults.  Therefore, I will encourage you to use this hyperlink:

https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk-in-the-lower-back/

Alternatively, try this link to OrthoBullets:

https://www.orthobullets.com/spine/2035/lumbar-disc-herniation

 

Like many problems in the musculoskeletal system, there can be significant differences between adolescents and adults, from presentation, to diagnosis, treatment and the short- and long-term outcomes.  Therefore, before we discuss the differences let us present some of the commonalities between adolescents and adults:

  • ·        Symptoms of low back pain, leg/hip numbness and pain and leg muscle weakness are similar. 
  • ·        Nerve root pain is caused by the disc material compressing the nerve root.
  • ·        Both typically have a more acute onset of back and leg pain symptoms, often related to a twisting/bending motion.

 

So what are the differences between adolescents and adults?

  • ·        “Arthritis” is common in adults and uncommon in adolescents. 
  • ·        Disc degeneration is required for a disc herniation in adults and often there are multiple levels which have degenerative discs.  “Only bad discs herniate”.
  • ·        In adolescents, disc degeneration sometimes is seen on MRI. 
  • ·        In adults, a piece of the degenerated disc is extruded backwards against the nerve roots (see below diagram).  In adolescents the small growth plate on the vertebra separates and this piece of bone and the attached soft tissues move backwards against the nerve roots (see below diagram).

In Adolescents: In the below diagram of the spine the normal ring apophysis (at green arrow) is a growth center in the developing spine and is a weak link when twisting and bending forces are placed onto the spine.  If overloaded, the ring fracture is pulled off the vertebra (black arrow) and moves toward the spinal canal (the area in blue).


 

In Adults: When the nerve root exits the spinal canal (green arrow) there is plenty of room without any areas of compression.  When the disc degenerates it will push a piece of the disc into the spinal canal and against the nerve root (red arrows) which can cause leg pain and numbness and muscle weakness in the leg.

 

 

 


 




Saturday, March 12, 2022

 

Blog Topic:  Bone Grafting in Spine Surgery

3-12-2022


In the previous blog post, we presented “what is a spine fusion”?

In most pediatric spine surgeries metal implants correct and stabilize the spine in a new position (see below), then a spine fusion is performed.


 

What I tell families/patients: “The metal allows us to attain and maintain the spine in a new position while the spine then creates a bony fusion” 

How do you get a spine to fuse? During surgery, after the implants are placed and the spine is corrected (see above), the fusion part of the surgery is then done. This involves decorticating, or roughening up, the bone in the back of the spine.  This stimulates the bone to heal, and the bone graft then is laid over this roughened bone.  The body breaks down, or digests this new bone graft and then creates a solid bony connection.

In the past, we used to always use the patients’ own bone, usually taken from the iliac crests above the hip joints. This type of bone is call “Auto-graft” = the patient’s own bone, whether it be from the spine, pelvis or both.


Harvesting the iliac crest bone takes additional time in the OR and it really hurts after surgery.  Since we have switched to allograft the amount of postoperative narcotics needed and the length of time patients’ were having significant pain has declined.

The standard of care now in pediatric spine surgery is to use allograft bone.  “Allo-graft” = another person’s bone. 




Bone is not rejected from the person receiving it, unlike in other type of tissue transfers between people.  There are no antigens on bone, unlike other transplanted tissue such as hearts or livers.

At present, during spine surgery there is some small amount of the autograft, or the patient’s own bone, which is collected during surgery, but the majority of the bone used is allograft.  So both types are used in deformity surgery, but most of the volume is because of allograft.

 








Wednesday, January 26, 2022

 

  Appointments: 314-514-3500                      Appointments: 314-432-3600

 


Blog Topic:  Latest Publication on Intraoperative Halo-femoral Traction

1-26-2022

 This study was just published in the Journal of Spine Deformity


 

For those interested to read more please use this hyperlink supplied by the publisher:

https://rdcu.be/cFHmd








Sunday, January 16, 2022

 

Blog Topic:  What is a “Spine Fusion”

1-16-2022


In the average, normal spine there are 7 cervical, 12 thoracic, and 5 lumbar vertebra, a sacrum and coccyx. 


From the skull to the sacrum, each vertebra is separated by a mobile disc, which is a highly complex structure which provides stability and motion at the same time.



In spinal deformity, such as scoliosis, the spine twists and bends, first through the discs and then the actual vertebra start to become misshapen, more trapezoidal instead of being more rectangular.

When we do surgery to correct spinal deformity (scoliosis) the first step is to get fixation into the vertebra so we can move those vertebra to a better, more desired position and then hold this new position firmly.  In 2022 the most secure and most commonly utilized spine fixation are metal pedicle screws (usually made of titanium +/- cobalt chrome), which are placed from the back of the spine, into the bone, through the pedicle and into the vertebra.


Alternatively, hooks, wires and bands can also be used but these are not as good a fixation option when compared to screws.

The next step is to connect these screws (or hooks, wires, and bands) together with rods.  These rods can then move the screws (or hooks, wires, and bands) to the desired position and then held rigidly in the new position.  These rods, in my practice, are 98% of the time are cobalt chrome, the stiffest metal currently available and can obtain the optimal 3-d alignment of the spine in my hands.

 

 

These metal screws and rods are VERY strong and durable.  However, we know the day we place them in surgery is when they are their strongest and have the strongest grip/fixation on the spine, and each day that goes by after surgery the metal gradually and almost imperceptibly gets weaker and the screws/hooks/wires/bands can get looser in/on the bone.


So 1 of 3 outcomes happen after we do spine surgery, at EACH VERTEBRAL LEVEL:

1.           1. The screws, hooks, wires, bands get loose from the bone.

2.          2. The rods, screws, hooks, wires and bands break.

3.           3. The spine fuses.


To achieve a spine fusion, we roughen the area to be fused with a drill, and then place bone graft.  The body then breaks down/dissolves the bone graft which is then used by bone cells to create a solid bony connection over the area we want to fuse.

 

The aim of bone graft is to develop a spine fusion before the spine implants get loose from the bone or break.

 

Next blog post will discuss the different type of bone grafts.

Sunday, January 2, 2022

 

Blog Topic:  What is ApiFix?

1-2-2022

In previous posts the Anterior Vertebral Body Tethering (VBT) has been presented.  This implant utilizes the flexibility of the growing thoracic spine, and its growth, to straighten the spine and then modulates its growth through the remainder of spinal growth.  There has been a lot of social media interest and publications about this procedure over the last several years touting its benefits, which are small incisions, rapid recovery, and the ability to correct the spine deformity yet not fuse the spine which preserves some of the spinal motion. The challenges of this procedure have also been well-documented, such as how much tension to apply to the tether/spine, how many levels to tether, and chronologic timing of the procedure (when to do the procedure).



Interestingly, an alternative procedure was approved the same month (8/2019), the ApiFix device.  There has been a lot less attention give to the ApiFix device, compared to the VBT procedure.  So the question is why?



Why has all the focus been on VBT and not ApiFix?

Some reasons:

1.      1. VBT has been used by pediatric spine surgeons in the U.S. since the 2010s, although in an unlabeled manner.  Whereas ApiFix was developed in Israel and used only outside the U.S.  Hence more surgeon in the U.S. are familiar to the VBT procedure than ApiFix

2.     2.  To many the ApiFix looks and acts similar to a traditional growing rod.  Whereas the VBT is inserted through small incisions, placed on the anterior spine and uses a tether as opposed to a lot of metal.

3.      3. Due to the longer surgeon experience with VBT, dramatically more research has been produced on VBT.

4.      4. Currently, any pediatric spine surgeon who undergoes a short training session can perform the VBT procedure.  For the ApiFix device the company is performing a study on all patients in the U.S., so all surgeons who use the device undergo more rigorous training and all patients will be studied.  This means there are far fewer surgeons in the U.S. performing the ApiFix surgery than VBT

5.      5. As a continuation of #4, since all patients are going to be in the FDA study on ApiFix there is strict criteria as to who can undergo the procedure.  The VBT procedure is left up to each surgeon to determine is applicability and effectiveness for each patient.


The effectiveness of VBT and ApiFix for each patient requires an in-depth discussion between patient/family and the surgeon.  At present there is no scientific evidence of the superiority of either system