Spine Surgery - non fusion

Article by Adjunct A/Prof Hee Hwan Tak

Spine Surgery - non fusion

Adjunct A/Prof Hee Hwan Tak

Orthopaedic Surgeon
National University of Singapore(NUS) 1990
Royal College of Surgeons of Glasgow 1995
Royal College of Surgeons of Edinburgh 1995
2000 Clinical Fellowship in Spinal Surgery in USA, training at the Tulane University, New Orleans, Louisiana and the University of Kentucky in Louisville and Lexington 
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Advances in Spine Surgery – the use of non-fusion methods

 

Spine surgery has undergone many advances over the past two decades. One of the main breakthroughs is the use of non fusion in spine surgery. In the past, surgical stabilization of the spine invariably will mean spinal fusion. There was no alternative.

While spinal fusion can remove the sources of pain as well as maintaining a proper spinal alignment, it has its disadvantages. Among the disadvantages include the loss of motion at the fused segment, leading to potential accelerated wear and tear of the neighboring segments of the spine. Sometimes, the spinal fusion will require the surgeon to obtain bone from the patient’s pelvis, leading to chronic hip pain. Patients also recover fairly slowly to their original lifestyle.

 

The advantages of non fusion are the preservation of motion at the operated segment, reducing the possibility of wear and tear of the neighboring segments. A faster recovery to work is also possible.

 

If one looks at the development of non fusion surgery in the other joints (hips and knees), they became the standard or gold standard treatment of choice in the 1980s. Development and acceptance of non fusion spine surgery took longer, as the mechanics of the spine are more complex. But in the 21st century, non fusion spine surgery certainly has a great role to play, in offering patients a viable alternative to traditional fusion surgery.

 

There are several types of non fusion spine surgery. They include:

1.      Percutaneous procedures performed under local anesthesia e.g. nucleoplasty

2.      Nucleus replacement of the intervertebral disc with annulus repair

3.      Total disc replacement

4.      Dynamic stabilization with either inter-spinous spacers or pedicle screw based devices

5.      Facet joint replacement (undergoing preliminary studies)

 

Nucleoplasty uses radiofrequency energy to dissolve the tissues of the nucleus, resulting in the reduction of pressure on the surrounding nerves. This radiofrequency energy used is of a lower temperature of 40 to 70 degrees Celsius, thus avoiding collateral damage to surrounding healthy tissues. Nucleoplasty can be sued in patients who have failed conservative treatment (e.g. physiotherapy and medications), but are not ready to undergo more major spine surgeries.

 

In early degeneration of the disc, partial replacement of the inner portion of the disc (nucleus replacement) maybe possible, along with repair of the annulus (the outer structure of the disc surrounding the nucleus). The nucleus is the structure that provides the “cushioning” properties to the intervertebral disc.

 

In more advanced degeneration of the disc, total disc replacement maybe needed. This is often done with the help of a vascular surgeon, as there is a need to gently move away the vital structures of the abdomen to reach and replace the disc.

 

Dynamic stabilization may be helpful in reducing the load on the operated segments or joints. In my practice, this is often used in conjunction with decompression of the affected nerve(s). A typical example is a patient with a large extruded disc compressing on the nerve. After microsurgery to remove the disc, as well as confirming that the nerve is free, we can insert a dynamic spacer between the spinous processes (bony structures that can be felt on our back).

 

In future, for advanced degeneration of the facet joints, the use of facet joint replacement may become a clinical reality if the on-going preliminary studies are encouraging.

 

 

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