Surgery

Minimally Invasive Surgery

Minimally Invasive Surgery is any procedure (surgical or otherwise) that is less invasive than open surgery used for the same purpose.

A minimally invasive procedure typically involves use of laparoscopic devices and remote-control manipulation of instruments with indirect observation of the surgical field through an endoscope or similar device, and is carried out through the skin or through a body cavity or anatomical opening. This may result in shorter hospital stays, or allow outpatient treatment.

A minimally invasive procedure is distinct from a non-invasive procedure, such as external imaging instead of exploratory surgery. When there is minimal damage of biological tissues at the point of entrance of instrument(s), the procedure is called minimally invasive.

We thank you for your cooperation and we hope to make your life a lot easier by relieving your pain!

You may wish to discuss risk and benefits with your pain doctor. Our pain doctors are highly trained and experienced to assure the greatest safety.

Spinal Fusion

Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to join two or more vertebrae.

Supplementary bone tissue, either from the patient (autograft) or a donor (allograft), is used in conjunction with the body’s natural bone growth (osteoblastic) processes to fuse the vertebrae.

Fusing of the spine is used primarily to eliminate the pain caused by abnormal motion of the vertebrae by immobilizing the faulty vertebrae themselves, which is usually caused by degenerative conditions. However, spinal fusion is also the preferred way to treat most spinal deformities, specifically scoliosis and kyphosis.

Spinal fusion is done most commonly in the lumbar region of the spine, but it is also used to treat cervical and thoracic problems. The indications for lumbar spinal fusion are controversial. People rarely have problems with the thoracic spine because there is little normal motion in the thoracic spine. Spinal fusion in the thoracic region is most often associated with spinal deformies, such as scoliosis and kyphosis.

Patients requiring spinal fusion have either neurological deficits or severe pain which has not responded to conservative treatment.

Conditions where spinal fusion may be considered:

• Degenerative disc disease
• Spinal disc herniation
• Discogenic pain
• Spinal tumor
• Vertebral fracture
• Scoliosis
• Kyphosis (i.e, Scheuermann’s disease)
• Spondylolisthesis
• Spondylosis
• Posterior Rami Syndrome
• Other degenerative spinal conditions
• Any condition that causes instability of the spine.

Microdiscectomy

Microdiscectomy (spinal decompression -) is a minimally invasive surgical procedure in which a portion of a herniated nucleus pulpolsus is removed by way of a surgical instrument or laser while using an operating microscope or loupe for magnification.

Spinal Cord Stimulation Therapy

A spinal cord stimulator is a device used to exert pulsed electrical signals to the spinal cord to control chronic pain.

Spinal cord stimulation (SCS), in the simplest form, consists of stimulating electrodes, implanted in the epidural space, an electrical pulse generator, implanted in the lower abdominal area or gluteal region, conducting wires connecting the electrodes to the generator, and the generator remote control. SCS has notable analgesic properties and, at the present, is used mostly in the treatment of failed back surgery syndrome, complex regional pain syndrome and refractory pain due to ischemia.

“Band-Aid”

Percutaneous Discectomy Surgical Procedure

The discectomy is performed through a cannula inserted through the back into the center of the vertebral disc under local anesthetic using a stylet. After the position of the stylet is confirmed to be correct using AP and Lateral X-ray views it is removed leaving the cannula in place. The disc material may be removed using surgical tools such as the Dekompressor or traditional manual surgical tools, however the manual instruments require a larger cannula and more disruption to the surrounding structures. Both the automated and manual percutaneous discectomy procedures produce similar results and reduction in disc height and pressure on the nerves to result in pain reduction.

Percutaneous Endoscopic Lumbar Discectomy

Percutaneous Endoscopic Lumbar Discectomy (PELD) is a step advance from lumbar microdiscectomy. PELD is a percutaneous surgical procedure for safe and sparing excision of herniated disc material. Even sequestered disc material – regardless of its size and level – that slipped into the spinal channel can be removed with the minimal invasive method.

Advantages of PELD

The PELD offers a number of advantages in comparison to conventional methods:

1. Immediate pain relief in 95% of the cases – study info needed
2. Direct access to herniated disc/sequester
3. The disc-annulus and the ligament remain intact
4. No general anesthesia, only a sparing local anesthetic necessary
5. Outpatient treatment
6. Shorter rehabilitation -study info needed
7. Faster return to profession and everyday life – study info needed
8. Small incision (only one stitch) = hardly any scarring

Prolotherapy

What is Prolotherapy?

Prolotherapy is also known as “proliferation therapy” or “regenerative injection therapy.” (“Proliferative Injection Therapy”) involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain.

It is thought to do so by re-initiating the inflammatory process that deposits new additional fibers to repair a perceived injury. Once strengthened, the weak areas no longer send pain signals.

Prolotherapy involves the injection of an irritant solution into an area where connective tissue has been weakened or damaged through injury or strain. Many solutions are used, including dextrose (a sugar), lidocaine (a commonly used local anesthetic), phenol, glycerine, or cod liver oil extract. The injection is given into joints or tendons where they connect to bone. The Injected solution causes the body to heal itself through the process of inflammation and repair. The process may result in as much as 30-40% strengthening of the connective tissue.

Is Prolotherapy something new?
Prolotherapy has been around since at least the 1950s, but most doctors reluctance to use different methods limited its acceptance. Recently, it has experienced a rise in popularity. Even our distinguished former Surgeon General, C. Everett Koop MD. has been treated with great success.

Is Prolotherapy safe?
It is safe, non-toxic and effective in most patients with chronic soft tissue pain. Our pain doctors are highly trained and experienced to assure the greatest safety.

Why does Prolotherapy work?
The theory behind Prolotherapy is that chronic soft tissue pain is the result of tears in the tissue, especially where it attaches to the bone. The periosteum is very pain-sensitive tissue, so weakened tissues and unresolved tears or sprains continue to produce significant pain. The solution used in prolotherapy produces an inflammatory response, which is followed by formation of new blood vessels and increases in collagen structure. The result is stronger tissue and reduced pain.

What kinds of medicines are used in Prolotherapy?
The Injections consist of hypertonic ( Proliferant ) solutions, such as Dextrose, Glycerol, Sarapin and Phenols, mixed with Local Anesthetic. No steroids. Do Prolotherapy Injections hurt? Well yes, but reproduction of the pain is an indication that the medicine is being deposited in the correct location. Some patients tolerated it very well, others less so. Your doctor mixes a numbing local anesthetic, which takes effect in a few short minutes, so it usually feel great right afterwards.

How often do I need Prolotherapy treatment?
Depending on the Pain Diagnosis and the extent of the pain, typically three to six sets of injections at intervals of 2 to 3 weeks are required. Sometimes the use of X-Ray guided Techniques are needed to reach the exact source of the pain.

Does Prolotherapy really work?
A careful examination and knowledge of Referral Pain Patterns is key to success. Success rates of 80% to 90% are reported when injections are performed by Doctors trained in diagnosis, patient selection, and appropriate technique. Prolotherapy can be considered for chronic pain conditions, such as chronic low back pain. Nearly 90% of acute back pain complaints resolve within 6 to 8 weeks with standard conservative treatment and do not require additional evaluation or specialized treatment.

What else should one do to increase the effectiveness of Prolotherapy?
Increase mobility and exercise as instructed, use a good nutritious diet, use your pain medicine as needed, and receive Prolotherapy or other treatments as prescribed.

Where else can we learn about Prolotherapy?
An Internet search using “prolotherapy” as the key word reveals a tremendous number of sites, as well as postings on pain-related message boards about prolotherapy-both for and against. The American Osteopathic Association and the American Association of Orthopaedic Medicine are excellent resources. Remember that Internet information is sometimes misleading, so use caution.

What specific conditions is Prolotherapy good for?
It is specific for back sprains and subluxations, for facet arthropathies, and for sacroiliac joint subluxations. The cervical spine responds better than the lumbar spine. This is probably a result of lumbar disc fissures that underlie chronic low back pain that are diagnosed due to poor response to prolotherapy or by Discogram. Prolotherapy is best for chronic back pain, non-discogenic, which is the 10% that does not resolve. Prolotherapy can be very useful in strains and sprains to the shoulders and limps. Prolotherapy should be performed only by physicians with expertise in this method.

Nerve Conduction Study

A nerve conduction study (NCS) is a test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body.

Nerve conduction velocity (NCV) is a common measurement made during this test. The term NCV often is used to mean the actual test, but this may be misleading since velocity is only one measurement in the test suite. Nerve conduction studies are used mainly for evaluation of paresthesias (numbness, tingling, burning) and/or weakness of the arms and legs. The type of study required is dependent in part by the symptoms presented. A physical exam and thorough history also help to direct the investigation. Some of the common disorders which can be diagnosed by nerve conduction studies are:

• Peripheral neuropathy
• Carpal tunnel syndrome
• Ulnar neuropathy
• Guillain-Barré syndrome
• Facioscapulohumeral muscular dystrophy
• Spinal disc herniation

Description

The nerve conduction study consists of the following components:

• Motor NCS
• Sensory NCS
• F-wave study
• H-reflex study

Motor NCS

Motor NCS are performed by electrical stimulation of a peripheral nerve and recording from a muscle supplied by this nerve. The time it takes for the electrical impulse to travel from the stimulation to the recording site is measured. This value is called the latency and is measured in milliseconds (ms). The size of the response – called the amplitude – is also measured. Motor amplitudes are measured in millivolts (mV). By stimulating in two or more different locations along the same nerve, the NCV across different segments can be determined. Calculations are performed using the distance between the different stimulating electrodes and the difference in latencies.

Sensory NCS

Sensory NCS are performed by electrical stimulation of a peripheral nerve and recording from a purely-sensory portion of the nerve, such as on a finger.The recording electrode is the more proximal of the two. Like the motor studies, sensory latencies are on the scale of milliseconds. Sensory amplitudes are much smaller than the motor amplitudes, usually in the microvolt (µV) range. The sensory NCV is calculated based upon the latency and the distance between the stimulating and recording electrode.

F-wave study

F-wave study uses supramaximal stimulation of a motor nerve and recording of action potentials from a muscle supplied by the nerve. This is not a reflex, per se, in that the action potential travels from the site of the stimulating electrode in the limb to the spinal cord’s anterior horn cell and back to the limb in the same nerve that was stimulated. The F-wave latency can be used to derive the conduction velocity of nerve between the limb and spine, whereas the motor and sensory nerve conduction studies evaluate conduction in the segment of the limb. F waves vary in latency and an abnormal variance is called “chrono dispersion”. Conduction velocity is derived by measuring the limb length in millimeters from the stimulation site to the corresponding spinal segment (C7 spinous process to wrist crease for median nerve). This is multiplied by 2 as it goes to the cord and returns to the muscle (2D). 2D is divided by the latency difference between mean F and M and 1 millisecond subtracted (F-M-1). The formula is 2D/(F-M-1).

H-reflex study

H-reflex study uses stimulation of a nerve and recording the reflex electrical discharge from a muscle in the limb. This also evaluates conduction between the limb and the spinal cord, but in this case, the afferent impulses (those going towards the spinal cord) are in sensory nerves while the efferent impulses (those coming from the spinal cord) are in motor nerves. This process cannot be changed.