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Spine Approach Surgery

Spine surgery can be a daunting idea to entertain. Most people, if they are contemplating the surgery, are either in significant pain, or they have been dealing with the problem for so long, that they are finally succumbing to the concept. Ultimately, the decision as to whether one needs surgery rests with the group of specialists involved, in conjunction with the patient. Usually the team will involve a Spine Surgeon, a Primary Care Physician, and a Physical Therapist and/or Chiropractor.

The Anatomy of the spine is important to understand.  Essentially, the spine is a column of bones called Vertebrae. The vertebrae are separated by a cushion of sponge-like structures called Discs. These discs allow the vertebrae to slightly angle forward and back, and side to side. The spine is the main structure holding the body upright from the pelvis to the head.  Additionally, the spine houses the all-important spinal cord, which is the neural connection from the brain to the rest of the body.

Pathology of the spine exists on many levels. The most common problem occurs when a disc begins to bulge outward and press or “impinge” upon the spinal cord. When this occurs, multiple symptoms can be seen. The symptoms are usually dictated by the level the impingement is located, as the level determines which nerves are affected.

Bulging Disc into Spinal Cord

 The most common impingement is L5/S1 which is at the lower end of the spine, called the sacrum. The symptoms here are commonly pain into the buttock and down the back of the leg. Additionally one may experience numbness, or weakness. Other levels of impingement which may occur higher up on the spine, for example in the Thoracic or Cervical Spine, will result in symptoms related to these locations. These symptoms may include groin or abdominal pain, or weakness, pain or numbness in the upper extremities.

MRI of Bulging Disc

 

The most common impingement is L5/S1 which is at the lower end of the spine, called the sacrum. The symptoms here are commonly pain into the buttock and down the back of the leg. Additionally one may experience numbness, or weakness. Other levels of impingement which may occur higher up on the spine, for example in the Thoracic or Cervical Spine, will result in symptoms related to these locations. These symptoms may include groin or abdominal pain, or weakness, pain or numbness in the upper extremities.

Bone on bone Compression

Finally, Spondylolisthesis is another entity which is where the vertebral bodies are not aligned vertically. The disc of one vertebra has shifted in relation to the rest of the column. Usually it has moved forward beyond the column causing, in some cases, pressure on the bones or spinal cord.

Spondylolithesis

When Spine Surgery is Indicated

In most cases, spine surgery can be avoided with proper rest, anti-inflammatory medications, and at times, steroids. A Physical Therapy protocol is usually started after the acute event in order to strengthen the structures in an attempt to prevent further issues.  Surgery may ultimately be required if multiple episodes of the same problem keep occurring, or the compression on the nerve results in a functional loss of the limb (the typical issue being a “foot drop”). The type of surgery required depends upon an algorithm which is specific to the anatomic problem, the patient’s age and health, and the solution that has the least amount of risk. The patient is involved with this decision making process.

Type of Approach

When spine surgery is indicated, two approaches are used in the majority of cases.  The posterior approach, which is the more common, is usually used for uncomplicated maneuvers. This is done with the patient lying face down in the prone position. An incision can be made over the spine in the back, and even smaller minimally invasive maneuvers can be done this way. Minimally invasive spine surgery, Micro-discectomy or Micro-decompression are terms which describe the procedure using a small incision and has been gaining popularity over the last decade.

Posterior Approach

More complicated problems often require an anterior, or less frequently a lateral approach. This is a surgery where the spine must be operated upon from the front or side, as the access needed is more extensive, and a wider area can be used. The patient is lying in a supine or face-up position, or sometimes a lateral or on-the-side position. Depending on what level the problem exists in the spine, the pelvis, the abdomen or the chest may be the zone which must be traversed.

Anterior Approach

 The anterior approach can be used for Disc Replacement, or Anterior Lumbar Interbody Fusion (ALIF).  A lateral approach can be used for a maneuver known as the Tethering Technique for scoliosis, or an Extreme Lateral Interbody Fusion (XLIF). Anterior and lateral approaches commonly require an Approach Surgeon, as the path to the spine is complicated and often involves moving structures aside. The Approach Surgeon is usually a General or Vascular Surgeon who assists the Spine Surgeon, as this is their area of expertise. The more complicated the approach, the more often an Approach Surgeon is required.

When is a Spine Approach Surgeon involved?

Usually the spine surgeon will arrange for an additional set of hands depending on the complexity of the case, the patient’s health status, the approach, and the structures which may be in the way. Examples of structures which may need to be retracted are the Aorta, Vena Cava, Iliac Artery or Vein, Spleen, Liver, and Kidneys. Sometimes the approach will need to traverse the chest cavity, so the Approach Surgeon will need to gain access to the spine by taking down the Diaphragm, and then repairing it at the end of the spine surgery.

Are all General Surgeons Spine Approach Surgeons?

Most General Surgeons indeed DO NOT perform approaches to the spine, and in fact, there are very few surgeons who have this type of experience and breadth of knowledge. Usually the Spine Surgeon will have worked with one or two individuals over the course of their career, where a significant amount of trust has been built between them. When a conversation about an operation takes place between the patient and the spine surgeon, the aspect of an approach surgeon will be discussed.

Who is the most experienced Approach Surgeon in the New York Area?

Dr. Sergei Dolgopolov is one of the most experienced Approach Surgeons in the New York area. He has practiced surgery for 35 years, and has been providing an extremely high level of care to hundreds of patients in this regard for nearly 20 years. Dr. Dolgopolov has worked with a multitude of different Spine Surgeons during this time, some of whom are the most prominent in the world. His care includes the choice of incision in regards to the anatomical aspects of the procedure, protection of the structures both vascular and otherwise, and monitoring in the post-operative period. As spine surgery has grown and become infinitely more complicated, Dr. Dolgopolov’s continued presence in the field for the last 20 years has enabled him to be part of, and even instrumental in the advances we have seen.