Posts Tagged ‘Spinal fusion’
How to Prevent Migraines
Throbbing headache. Blurred vision. Sensitivity to light and sound. Nausea. Sound familiar? At least 16 to 17 percent of the world’s population will experience a migraine at some point in their lives, but for many, migraines are a part of daily life.
A migraine can be simply debilitating, when all you can think about is getting to a dark, quiet place to lie down and rest. Migraines can mean missing work or school, and even missing out on important, they-only-happen-once, life events.
There are some medications that can reduce the number and severity of migraines, but lifestyle changes are also strongly recommended to help prevent and/or alleviate the pain associated with migraines. If you suffer from migraines, try these migraine prevention tips.
- Get regular exercise. Aerobic exercise helps to reduce tension and prevent migraines. Choose a form of exercise you enjoy — walking, swimming or cycling or even dancing. Make time for 30 minutes of aerobic exercise every day. Exercise also aids weight loss, which may also help to prevent migraines.
- Avoid migraine triggers. For many people, migraines are triggered by certain food or scents. If you notice that a specific food or scent has triggered migraines in the past, try to avoid them.
- Get plenty of rest. Regular sleep patterns can help to reduce tension and stress that lead to migraines. Establish a regular sleep pattern means going to bed and getting up at the same time, every day. To help yourself sleep, turn off all electronics at least an hour before your bedtime, turn down the lights and allow yourself to relax.
- Reduce stress. Stress is a common cause of migraines. Find ways to reduce your stress, whether through exercise, meditation or simply relaxing at home.
- Reduce estrogen levels. For some women, estrogen can induce migraine headaches or make them work. If this is the case for you, avoid medications such as birth control and other hormone pills that contain estrogen.
If you suffer from chronic migraines, talk with your doctor about pain management and lifestyle changes that may help reduce your headache main.
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Stem Cells for Spine Surgery: 7 Points
Written by Laura Miller | May 23, 2012
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How we got here
Dr. Hynes was one of the many spine surgeons who participated in Medtronic’s original trials for BMP-2 in the 1990’s. While scientists have known about the ability of stem cells and BMP to generate bone for several years, Medtronic was the first company to develop a safe and effective molecule to stimulate cell growth. After completing the pre-market approval trials, the Food and Drug Administration granted approval for the BMP-2 product, Infuse, in 2002 for creating fusion in the Lumbar Spine placed through an anterior approach in a LT cage.
“In the original study, I experienced 100 percent of enrolled patients in my Practice achieving bone growth when combining BMP with the local cells that were already there,” says Dr. Hynes. “Local ‘stem cells’ respond to BMP and become activated thereby creating bone. When I saw it worked in 100 percent of my enrolled patients, I was a true believer. I have used it in my practice since the study and FDA approval going back greater than 10 years.”
What has changed is our ability to concentrate stem cells; Dr. Hynes harvests the stem cells from the iliac crest to combine with the BMP. It takes less than five minutes for his physician’s assistant to harvest the cells, which are spun in a centrifuge while he begins the operation. After 10-15 minutes, the cells are ready and Dr. Hynes adds a small amount to the surgical field along with the BMP. The collagen sponge is placed within an interbody LT cage to keep the material from migrating.
“This has been an effective Bone Graft method and it has been an advantage for my patients who can avoid Iliac Bone Graft surgery and Donor Bone issues and cost,” says Dr. Hynes. “It doesn’t add to my usual procedure time. It does add a small cost, but I find it’s worth the value proposition.”
Since its inception and release, surgeons have been experimenting with its use in several different capacities, on- and off-label. However, articles published in The Spine Journal in July 2011 suggest complication rates may be higher than the original studies reported. Several physicians have reported positive and negative events based on individual practice date, and further research into its use will be necessary going forward. As with all products, on label and off label use is routine practice and common place. When used correctly, minimal side effects of swelling, seroma and osteolysis occur.
What the research says
There have been several clinical studies and basic science research projects published in professional journals discussing the efficacy of using BMP with local stem cells to enhance fusion. However, research on the impact of increasing the number of stem cells is still lacking. Dr. Hynes’ current clinical work focuses on whether there is a better chance of achieving fusion with a higher concentration of stem cells.
He harvests stem cells from the iliac crest, percutaneously and painlessly, or vertebral body and extract about 60-80 ccs of blood. The desired stem cells are concentrated to a few ccs with centrifugation and has about a 50,000 cell count per “Spine Smith research data.”
“We already know the mechanism by which BMP-2 activates stem cells. The stem cells are already very effective,” says Dr. Hynes. “If we add to the population of stem cells that are already there that are available to regenerate new bone, it could make the procedure even better. Anecdotally, I have a high fusion rate for my spine patient population even before adding the extra concentration of stem cells. With the additional stem cells, I hope to achieve fusion at almost any level no matter how many levels are needed such as in degenerative scoliosis. In osteoporosis and aging spine patients, this has been extremely beneficial when compared to poor iliac crest from bone harvest.
Dr. Hynes’ ethereal practice goal is to someday be able to “guarantee” that they will achieve fusion for every patient who undergoes surgery. This means stabilization. However, fusion does not guarantee “success” of the surgery but increases odds of the surgical success. At this point, he is close, with approximately a 95 percent fusion rate. “What I want to do before I retire is to be able to guarantee a fusion,” he says. “I can’t guarantee pain relief or other clinical outcomes, but I want to be able to confidently guarantee the fusion or stabilization component.”
Options for harvesting stem cells
There are several bone graft options spine surgeons can choose from to achieve a fusion, and in the wake of recent controversies some surgeons are looking for an alternative to using BMP. Surgeons can go back to the traditional fusion method – the iliac crest – or using an allograft. Dr. Hynes says harvesting bone from the iliac crest can leave 30 percent of patients in more pain and add significant surgical time in the OR with increased blood loss. Allografts also have downsides, including graft consistency, quality, processing issues and less potential to achieve fusion than iliac crest or autogenous grafting methods.
“The bone for allografts may not be prepared correctly,” says Dr. Hynes. “We don’t always know the quality or consistency of the allograft compared to the patient’s natural bone. If I’m putting a piece of bone in patients, it’s better if it comes from their own bodies. That way, you can’t tell the difference between the bone you grow and the natural bone. (What we are doing is creating a nice bone graft that balances the biomechanics of the fusion construct better than the allograft.)”
In some cases, the allograft bone could migrate or fracture or reabsorb after the procedure, which can cause significant pain and complications, often resulting in revision procedures. By using the combination of BMP and stem cells in an interbody device, Dr. Hynes is able to avoid most of those complications because the cells are attracted to the BMP, which is restrained in the cage.
Patients should have the final say – “Informed Consent”!
Like many surgeons, Dr. Hynes describes the different fusion options to his patients and allows them to choose which procedure they feel most comfortable with. He discusses the pros and cons of each technique, including the most recent concerns about BMP, as well as his personal outcomes. He says patients often choose BMP combined with stem cells because they like the idea of regenerating their own bone naturally, avoiding the extra surgery and potential pain of iliac crest bone grafts and decreased potential or effect of donor allograft bone.
“The psychology of healing is part of this,” says Dr. Hynes. “Patients understand the procedure and like the idea of using their own cells as healing factors. People are very positive about that process because they feel like they are doing something natural instead of synthetic. Healing and surgery isn’t just biomechanics and science; it’s psychological as well. Successful outcomes of surgery depend on subjective relief as well as objective factors.”
In his practice, Dr. Hynes says a significant number of his patients chose the BMP and stem cell combination with given the option. However, when the patients choose a different option, he performs the other procedures as well. “It’s our duty to give patients their choice,” he says. “I’m not always smart enough to know what the best choice is for any one individual, but I’ve practiced many years and learned that if you take time to educate patients to all the reasonable options, they will make good decisions and take responsibility for them.”
Deciphering the complications
While Dr. Hynes hasn’t experienced significant complications among his patients, it’s clear that other surgeons have reported complications when they perform spinal fusions using BMPs. One reason for the discrepancy could be the dosage; well-documented evidence suggests that a higher dosage of BMP could cause swelling complications when used in the cervical spine. By using low doses of BMP and a pre and post-surgical protocol, swelling is completely avoidable in the cervical spine. Another factor is the surgical approach; Dr. Hynes says retrograde ejaculation (“RE”) – one of the severe complications mentioned in the studies this past summer – is a complication risk of any anterior spine surgery and not related to use of BMP. “I have performed thousands of anterior procedures before and after approval of BMP for anterior lumbar surgery and I find no difference in RE noted in my patients.”
“Every spine surgeon knows RE is a risk during anterior procedures and it usually will reverse on its own,” says Dr. Hynes. “RE occurs in an extremely low frequency. RE occurs because of disruption ‘surgically’ of small nerves to a sphincterine the bladder. BMP does not cause this effect, but the use of the electrocautery tool, during surgery, likely does. Use a small dose of BMP and a cage as well.”
In his practice, Dr. Hynes has never experienced a critical airway complication using cervical BMP. In early years, too high a dose would lead to swelling but not airway compromise which more commonly occurs with hematoma or blood clot, says Dr. Hynes. Papers published in The Spine Journal also mention cancer as an associated complication, which is something he hasn’t necessarily noted either. “I haven’t seen a rash of cancer in my patients, but I haven’t been surveying for it either,” he says.
He is currently going through his patient base to determine whether he can detect any cancer cases that could be associated with the procedure.
Whether to use BMPs
As surgeons report different findings based on their individual practice data, many of the studies and discrepancies have been reported in the media. However, full understanding of these complex issues is often lost in news reports. “I hate to see some of the surgeons and journals duking it out in the media,” says Dr. Hynes. “That isn’t the place to argue over the efficacy of stem cells and BMPs. We have to do it in the meetings where people understand the context. To lay this out in the newspapers exacerbates political agendas and confuses our patients. We need to speak honestly with each other about this at professional and scientific meetings, not in the press.”
This controversy isn’t the first time new spinal technology and procedures have been under attack. For a period of time, pedicle screws – which are a standard of care now – were under the microscope because complications were reported. In some instances, surgeons were sued and restricted from use at their hospitals for their alleged unfavorable outcomes. Now pedicle screws are the mainstay of spinal fusion procedures.
“At the time, there was only approval that pedicle screws could be used on single-level surgeries,” says Dr. Hynes. “Now we use them at multi-levels. The pedicle screws ultimately won the day, but with public stimulation ‘in the news’ in the early 1990s, we almost lost the ability to use them. This was a public attack on the advent of a new fusion technology, and now we are seeing similar phenomenon’s with BMP and other medical products.”
Covering the cost of BMP
In some cases, surgeons may have a difficult time receiving reimbursement for BMP products because they were more expensive in the past. Dr. Hynes and his colleagues have worked with hospitals and surgery centers to cover the cost in both out-of-network and in-network contracts. In some cases, patients are willing to cover the cost of using stem cells with BMP. Due to the success and demand, the cost has now become competitive considering operative costs of iliac bone surgery or allograft. “The increased volume of use and effectiveness has caused a dramatic decrease in cost,” says Dr. Hynes.
“I see patients from out of the Country and they are usually cash pay patients,” says Dr. Hynes. “We have to line item every part of the procedure to show the actual cost and there is almost no increased cost for the use of low concentrated BMP compared to iliac bone grafts or allograft when taking OR time, surgeon’s time and other OR costs into consideration.”
Fortunately, the hospitals in Dr. Hynes’ community allowed him to use BMP and conduct the clinical studies there. “We have more experience in our community with the benefits of this technology because we started so early,” he says. “Our surgeries are very efficient and our operative time is less because of our long-term experience with the procedure using stem cells and BMP.”
However, in some cases Dr. Hynes has made sacrifices to mitigate these costs. “I think about what I could live without and forego those expenses for stem cells and BMP,” he says. “I might use less expensive blades or a new set of tools for the next year. I might continue to use my old led apron or do surgery without a super drape. I’m there to give patients a better outcome and I want to make sure they have the opportunity to have the stem cells.”
More Articles on Spine Surgeons:
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6 Spine Surgeons on How Young Surgeons Can Position Themselves for Success in the Future
What Percentage of Your Spine Practice is Medicare Patients?
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Kyphoplasty Surgery, Kyphoplasty, Kypho, Vertebroplasty, Back Surgery, Spine Surgery
What is Vertebroplasty & Kyphoplasty?
Vertebroplasty and kyphoplasty are minimally invasive procedures for the treatment of vertebral compression fractures (VCF), which are fractures involving the vertebral bodies that make up the spinal column.
When a vertebral body fractures, the usual rectangular shape of the bone becomes compressed, causing pain. These compression fractures may involve the collapse of one or more vertebrae in the spine and are a common result of osteoporosis. Osteoporosis is a disease that results in a loss of normal bone density, mass and strength, leading to a condition in which bones are increasingly porous, and vulnerable to breaking. Vertebrae may also become weakened by cancer.
In vertebroplasty, physicians use image guidance to inject a cement mixture into the fractured bone through a hollow needle. In kyphohplasty, a balloon is first inserted into the fractured bone through the hollow needle to create a cavity or space. The cement is injected into the cavity once the balloon is removed.
Performing Kyphoplasty Surgery
- During kyphoplasty surgery, a small incision is made in the back through which the doctor places a narrow tube. Using fluoroscopy to guide it to the correct position, the tube creates a path through the back into the fractured area through the pedicle of the involved vertebrae.
- Using X-ray images, the doctor inserts a special balloon through the tube and into the vertebrae, then gently and carefully inflates it. As the balloon inflates, it elevates the fracture, returning the pieces to a more normal position. It also compacts the soft inner bone to create a cavity inside the vertebrae.
- The balloon is removed and the doctor uses specially designed instruments under low pressure to fill the cavity with a cement-like material called polymethylmethacrylate (PMMA). After being injected, the pasty material hardens quickly, stabilizing the bone.
Kyphoplasty surgery to treat a fracture from osteoporosis is performed at a hospital under local or general anesthesia. Other logistics for a typical kyphoplasty procedure are:
- The kyphoplasty procedure takes about one hour for each vertebra involved
- Patients will be observed closely in the recovery room immediately following the kyphoplasty procedure
- Patients may spend one day in the hospital after the kyphoplasty procedure
Patients should not drive until they are given approval by their doctor. If they are released the day of the kyphoplasty surgery, they will need to arrange for transportation home from the hospital.
Recovery from Kyphoplasty
Pain relief will be immediate for some patients. In others, elimination or reduction of pain is reported within two days. At home, patients can return to their normal daily activities, although strenuous exertion, such as heavy lifting, should be avoided for at least six weeks.
Candidates for Kyphoplasty
Kyphoplasty cannot correct an established deformity of the spine, and certain patients with osteoporosis are not candidates for this treatment. Patients experiencing painful symptoms or spinal deformities from recent osteoporotic compression fractures are likely candidates for kyphoplasty. The procedure should be completed within 8 weeks of when the fracture occurs for the highest probability of restoring height.
It is not known whether kyphoplasty or vertebroplasty will increase the number of fractures at adjacent levels of the spine. Bench studies on treated bone have shown that inserting PMMA does not change the stiffness of the bone, but human studies have not been done. Osteoporosis is a chronic, progressive disease. As stated earlier, patients who have sustained fractures from osteoporosis are at an increased risk for additional fractures due to the loss of bone strength caused by osteoporosis.
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Regenerative Medicine
Administering undifferentiated stem cells to an injured disc has made adult stem cell regenerative medicine in spine a reality. Adult stem cell regenerative medicine holds the promise of stabilizing or even reversing the degenerative changes associated with aging or following traumatic injury. Current clinical use of stem cells is very limited, in part by the cumbersome approval process. The use of concentrated bone marrow aspirate (BMC) as a “stem cell” preparation is currently the simplest and safest way of utilizing the regenerative potential for mesenchymal stem cells (MSCs) to promote tissue regeneration. In fact, stem cells concentrated from bone marrow have been shown to stimulate the formation of bone, cartilage, ligament and tendon, and dermal tissues.
Conservative treatment options for lumbar and cervical pain associated with discogenic disc disease (Pfirrmann Grades 3-6) are limited. Treatment options include pain medication, steroids, physical therapy, and chiropractic care. Reversal of disc pathology has not been achieved with current available treatment modalities. Failure of these nonoperative treatments may leave surgical intervention as a treatment option.
The goal of utilizing MSCs is to not only potentially provide pain relief from the painful degenerative disc, but to reverse the degenerative process. There are three methods for placing MSCs into the painful nucleus pulposus.
The use of allogeneic mesenchymal precursor cells (MPCs) is currently being evaluated as a part of an FDA Phase I clinical trial. Extracted from donors and expanded in number by tissue culture, this process isolates and grows the stem cells into pure MPCs which are injected into the nucleus pulposus. This technology does not have FDA approval.
Utilizing expanded, autologous MSCs for injection into the painful disc is the second method. Federal regulations require the approval of an Investigational New Drug application supported by prospective, randomized clinical trials for the use of expanded autologous MSCs. The FDA has not approved this technology.
The third method involves autologous point of care therapy. This technology does not require FDA approval. The patient’s own MSCs are directly injected into the nucleus pulposus of the symptomatic degenerated disc(s) using standardized two needle discography technique. This requires fluoroscopic visualization and 2-3cc of MSCs are slowly injected into the symptomatic nucleus pulposus.
There have been no complications associated with the iliac crest aspiration or disc injection. Thus far no patient in the study has undergone spine surgery following treatment. Results obtained with this technique suggest its potential clinical efficacy in the treatment of moderate to severe degenerative disc disease. These results require verification with longer follow-up and randomized prospective studies.
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Confusion about Spinal Fusion, Spine Fusion, Spine Fusion Surgery, Back Fusion Surgery, Back Surgery
Spinal Fusion is used to treat spinal instability and alleviate chronic mechanical back pain but many people are unsure of what spinal fusion actually does. Spinal fusion is surgery to permanently connect two or more vertebrae in your spine, eliminating motion between them.
Spinal fusion involves many techniques designed to mimic the normal healing process of broken bones. During spinal fusion, your surgeon places bone or a bone-like material within the space between two spinal vertebrae. Metal plates, screws and rods may be used to hold the vertebrae all together, so they can heal into one solid unit.
Because spinal fusion surgery immobilizes parts of your spine, it changes the way your spine can move. This places additional stress and strain on the vertebrae above and below the fused portion, and may increase the rate at which those areas of your spine degenerate.
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Robotic Guided Spine Surgery, State Of The Art Spine Surgery Technology, Robotic Spine Surgery, Spine Surgery Robot
Spinal disorders encompass a spectrum of pathologies which result in either pain, deformity or paralysis to the patient.
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No age is spared and the need for the surgical correction of the problem crosses the barrier of age and gender. Most of the surgical procedures involve the fusion, stabilization or correction of the deformity or pathology by putting in screws in the individual vertebrae. Screw placement is fraught with inherent risk of injury to the nerves, spinal cord or blood vessels, as it is a free hand procedure based on the surgeon’s orientation of the anatomy and guided by a radiological device called C arm. The disadvantage was the lack of accuracy in these machines to detect possible injury to the vital structures in complex anatomical deformities of the spine or in patients who were already oper-ated and needed a revision surgery. Thus a need for a more accurate and safe guidance device to improve the safety levels in screw placement was increasingly felt. The concept of a monitoring and navigating device to aid the surgeon in operating on deformed and crooked spines has been developed since the late 1990s. The early systems rely on the use of reference points on the spine, which are fed into a computer which calculated the path of a safe screw in the vertebra, based on a CT scan reconstruction of the spine. This system has its own flaws and required the surgeon to navigate the spine, which makes the process cumbersome. Moreover the accuracy of such systems in large trials was suspect, as it is still a free hand procedure. This led to the development of a highly advanced state of the art technology, where a small robot aligns itself in the direction of the pedicle, which is a part of the backbone where the screws are put. The robotic arm is moved by a software which matches the preoperative high resolution CT scan of the patient’s spine with the images of the patient’s spine captured by a C-arm, which is a portable X-ray device used to see the bones during orthopedic surgery. Once the bones are matched and the individual parts are registered on the machine this aligned robotic arm guides the surgeon to place the screws in a very accurate fashion. The path of the screws is planned by the surgeon on the day prior to the surgery on a computer. All the details of the surgery including the sizes of the screws and implants, number of implants and the various other angles and distances for the respective screws are programmed by the surgeon. On the day of the surgery, these details are available to the surgeon at the click of a button. This makes the whole procedure faster, safer and more accurate. The recent advances in spine surgery has included Minimally Invasive Spine Surgery, also called Keyhole surgery in common parlance. In these surgeries, the skin is not cut in great lengths on the back. The entire surgery is done through one or more small incisions the sizes of small keyholes. This gives the patient the advantage of a faster return to work and easier rehabilitation, lesser blood loss and pain. For these types of surgeries, a number of X rays are taken during the surgery to determine the correct level and the exactness of implant placement. This endangers the patient, surgeon and other operating room personnel to a lot of radiation hazards. The robotic guided surgery decreases the amount of radiation exposure by 10 times vis-à-vis a standard keyhole procedure. Ever since the Spine Surgery Unit headed by Dr Sajan Hegde conceived of getting this technology to India for the first time, it has been followed very keenly in the hospital. The robotic guidance system called Mazor Rennaisance, is developed by an Israeli company called Mazor Robotics Limited. The company sent its prog-rammers and trainers to Chennai to our Hospital to train and instruct the various theoretical and practical intricacies. An instructional course with training was given to the surgeons, OT nurses and all the other involved personnel. A dry run on bone models was carried out and once it was sure that all the systems necessary were in place, only then Dr Hegde’s team went ahead and performed the surgeries. Since the whole team was new to this procedure, a few technicians and programmers from the company came down to India along with the machine and helped in the initial few surgeries to avoid any glitches. Since its launch to date, close to 20 spine surgeries have been operated, some of which were extremely complex deformities and would have been very difficult, if not impossible to perform without guidance. One young girl, who had been operated many times on her back for her scoliosis with failures at each attempt, came to us with a desire to get operated for the deformity. During the surgery we saw that the whole of the anatomical landmarks necessary for the free hand placement of the implants was lost and there was no way the screws could have been put. It was at that time we realized the value of the robotic guided system to enable us to place the screw in the bone without any damage to the blood vessels or nerves. Another patient who was suffering from severe kyphosis (hunch-back) due to a disease called Ankylosing spondylitis was operated with a deformity correction and eventual straightening of the back. Many of the surgeries which were planned to be done in the minimally invasive way were executed with as less as 10% of the radiation in a standard C arm guided keyhole surgery. There are patients in whom the robot has been used to obtain tissue for biopsy from an exact preplanned location, as in the case of an elderly woman with breast malignancy and metastases to the spinal column. Another useful instance has been in a middle aged lady who had a severe scar on her back due to a previous burn. This lady came to us with infection of the backbone and incomplete paralysis of the lower limbs. Since the skin of the back did not permit a standard open back surgery, a keyhole stabilization was done beautifully using the robot. Planning and executing of this project was both technically and logistically difficult. There were initial teething problems in getting everything to fall in its place. The time taken in the initial surgeries was slightly long. But the learning curve became shorter with each case. Once all the participants in the surgery were familiar with the procedure of the robot, the surg-ical times decreased drastically. Also the understanding of the system improved and hence a smooth flow was seen in the oper-ation theatre in the subsequent cases. This technology (Rennaissance, Mazor) has helped us to achieve accuracy levels as high as 98% compared to a standard free hand accuracy which rarely exceeds 90 percent. More so in the scenario of a very complex deformity in young adults or children where the risk of improper and dangerous surgery is high, the robot has assured the surgeon and the patient with the high safety levels it provides. Though the instrument is expensive and requires the use of a certain amount of disposables each time, the actual cost incurred to the patient rarely exceeds an additional 20 percent on the total expenses for the surgery. The patient can be comfortable knowing that the surgery planned is a highly accurate one and that there is no scope for any untoward complication. Thus the benefits compared to the extra cost involved are high enough to take this up. With respect to the hospital, we can be proud that we are the first hospital to introduce this technology in Asia (outside of Israel ), beating countries like China , Singapore , Japanand Korea to the mark. This has helped brand our hospital as a pioneer in the safe management of complex and otherwise dangerous spinal deformities. As of date, we have patients from other countries too who have been operated using this state of the art technology. This bears testimonial to our superiority in technology advancement in the field of spine surgery, making our hospital one among the top centers in the world. The operating room personnel too are benefitted as the radiation exposure due to an image intensifier is reduced to miniscule proportions. The surgeon and his team, at the end of the day, return home with the satisfaction of having done an accurate and safe surgery. At the same time we would like to also mention that the surgery as such is normal as a conventional surgery, but the robot finds the safest possible path. In that sense the robot does not replace the surgeon, as is the normal misconception. On the contrary, the surgeon is backed up by the foolproof planning done prior to the surgery on the robotic software. Our review of all the patients operated has been excellent and we can confidently assert that the robotic guided surgery has made spine surgery a safer proposition, in addition to reducing the stress on the surgeon and his team in the operation theater. The future of spine surgery is shaping in the direction of minimally invasive surgeries where the stress shall be on earlier return to productive activity to the patient and reduction of the hospital stay and expenses. From the surgeon’s perspective too, the use of the robotic guiding systems would mean more safety levels, lesser radiation hazards and stress free situations in the operating room. |
Technology is ever advancing and it is the duty of the medical fraternity to keep abreast with it as the patient has the right to benefit from every such advancement.
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Lumbar and Cervical Radiofrequency Ablation and Lesioning
What is Radiofrequency?
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Radiofrequency waves are electromagnetic waves which travel at the speed of light, or 186,000 miles per second (300,000 km/s). Radiofrequency Energy is a type of heat energy that is created by a special generator at very high or super high frequencies. With the use of this specialized generator, heat energy is created and delivered with precision to target nerves that carry pain impulses. The resulting “lesion”involves a spherical area of tissue destruction at the tip of the RF needle that can include pain-carrying nerves.
Why is this procedure done?
Radiofrequency ablation/lesioning is a procedure used to provide longer term pain relief than that provided by simple injections or nerve blocks. Many patients who are being considered for this procedure have already undergone simple injection techniques like Epidural Steroid Injection, Facet Joint Injection, Sympathetic Nerve Blocks, or other nerve blocks with pain relief that is less prolonged than desired. By selectively destroying nerves that carry pain impulses, the painful structure can be effectively denervated and the pain reduced or eliminated for anywhere from a few months to up to 12 months.
How is this procedure done?
Once a structure has been determined to be a pain generator, its nerve supply is targeted for interruption. A small insulated needle or RF cannula is positioned next to these nerves with fluoroscopic guidance (live video X-Ray). Your doctor knows where to place the RF cannula because he is an expert in anatomy. The shaft of this cannula except for the last 5 to 10 mm is covered with a protective insulation so that the electric current only passes into the surrounding tissues from the very tip of the cannula. When the cannula appears to be in good position, the doctor may perform a test and release a small amount of electric current through the needle tip at two different frequencies. This test helps to confirm that the cannula tip is in close proximity to the target nerve and that it is not near any other nerve. After a successful test confirms good cannula tip position, a local anesthetic is injected to numb the area. The RF generator is then used to heat the cannula tip for up to 90 seconds, and thus the target nerve is destroyed.
What types of conditions will respond to Radiofrequency Lesioning?
There are a multitude of chronic pain conditions that respond well to this treatment. Chronic spinal pain, including spinal arthritis (spondylosis), post-traumatic pain (whiplash), pain after spine surgery, and other spinal pain conditions are those most commonly treated with RFL. Other conditions that are known to respond well to RFL include some neuropathic pain conditions like Complex Regional Pain Syndrome (CRPS or RSD), peripheral nerve entrapment syndromes, and other assorted chronic pain conditions. A patient’s candidacy for RFL is usually determined by the performance of a Diagnostic Nerve Block. This procedure will help to confirm whether a patient’s pain improves just for the duration of the local anesthetic (or not). Patients who have little to no pain relief after a diagnostic nerve block are not candidates for a neurodestructive procedure like RF Lesioning.
Does the procedure hurt?
This procedure is no more painful than any other injection procedure that is performed in interventional pain management. Patients are often given mild intravenous sedation during the procedure, but sedation is not absolutely required. Deep sedation is not a safe alternative and is therefore not offered for my RF procedures. It is quite common for neck or back pain to increase for a few days or longer after the RFL procedure before it starts to improve.
What should I do to prepare for my procedure?
On the day of your injection, you should not have anything to eat or drink for at least eight (8) hours before your scheduled procedure. If you are scheduled to receive sedation during the procedure, you must have someone available to drive you home. If you usually take medication for high blood pressure or any kind of heart condition, it is very important that you take this medication at the usual time with a sip of water before your procedure.
If you are taking any type of medication that can thin the blood and cause excessive bleeding, you should discuss with your doctors whether to discontinue this medication prior to the procedure. These anticoagulant meds are usually prescribed to protect a patient against stroke, heart attack, or other vascular occlusion event. Therefore the decision to discontinue one of these medications is not made by the pain management physician but rather by the primary care or specialty physician (cardiologist) who prescribes and manages that medication. Examples of medications that could promote surgical bleeding include Coumadin, Plavix, Aggrenox, Pletal, Ticlid, and Lovenox.
What should I do after my procedure?
Following discharge home, you should plan on simple rest and relaxation. If you have pain at the needle puncture sites, application of an ice pack to this area should be helpful. If you receive intravenous sedation, you should not drive a car until the next day. Patients are generally advised to go home and not return to work after this type of procedure. Some patients do return to work the next day.
Could there be side effects or complications?
BecomePainFree Doctors will discuss these issues with you, and you will be asked to carefully read and sign a consent form before any procedure is performed.
Can this procedure be repeated if my pain returns?
It is possible for the treated nerve(s) to regenerate, which could lead to recurrent pain. However, RF Lesioning is repeatable for nerve regeneration if it worked the first time around.
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Fax #: (888)238-9155 | E-mail Us or https://www.becomepainfree.com/
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Mayo Clinic, Spine Surgeon, Mayo Clinic Back Surgeon, Mayo Clinic Pain, Mayo Clinic Fellowship Trained Surgeon, Mayo Clinic Doctor, Mayo Clinic Back pain
We have two spine surgeons in our group and one on the way from the world famous Mayo Clinic. These Mayo Clinic surgeons are some of the best in the United States of America both of these Mayo Clinic trained doctors work in Texas. Dallas, Fort Worth, San Antonio we ave you covered with Mayo Clinic trained spine surgeons. Here is the information on these doctors below.Check out our website at https://www.becomepainfree.com/
Call Us: (214) 396-3647 | (888) 373-3720
Fax #: (888)238-9155 | E-mail Us
Steven J. Cyr, M.D., FAAOS
Mayo Clinic Trained Spine Physician
Steven J. Cyr, M.D., is a Board Certified Orthopaedic Surgeon who received extensive training to specialize in the delicate science of Spine Surgery. Anyone who knows Dr. Cyr well will tell you that he is a man driven for quality and excellence. His high standards can be seen throughout his educational process and career.
He received top honors at Southwest Texas State University by graduating Summa Cum Laude and Valedictorian with a Bachelor of Science in Biology. In addition to rigorous academics, he was also a member of the Bobcat football team during his three years at SWTSU.
Dr. Cyr gained early acceptance into medical school and earned his MD from the University of Texas Health Science Center in San Antonio. He then began his service to the United States Air Force with a transitional internship at Wilford Hall Medical Center. He served the air force community as a flight surgeon for two years before beginning residency training in orthopaedic surgery at Wilford Hall.
Following residency, Dr. Cyr was honored to be chosen from among the country’s top residents as the only fellow for the highly competitive and prestigious spine fellowship at the Mayo Clinic in Minnesota. This training program has ranked number one for orthopaedic and neurosurgical training programs in America for the last 20 years. Mayo combines these two fields, giving their surgeons an understanding of nerve and spine function unparalleled in most other programs.
Upon completion of his fellowship, Dr. Cyr and his family moved back to San Antonio, where he served the military population as the Chief of Air Force Spine Surgery and Spine Surgery Consultant to the Surgeon General of the Air Force. For six years, Dr. Cyr taught future air force orthopaedic surgeons in residency at Wilford Hall and has twice served our war wounded in Iraq at the Air Force Theater Hospital in Balad.
He has brought innovative techniques to the military and was the first to perform the total disc replacement procedure as well as endoscopic spinal surgery. He specializes in complicated spine issues and has gained notoriety for successful repairs of failed surgeries on patients from numerous other states and around the world. Dr. Cyr’s expertise and skills are now available to civilian patients at the Orthopaedic and Spine Institute, where his passion for excellence and quality keep him at the leading edge of spine surgery.
Mayo Clinic Trained Spine Physician
Dr. Venkat Sethuraman M.D.
Mayo Fellowship Trained Board-Certified Spine Surgeon
Minimally Invasive Spine Specialist
Education Undergraduate: Rutgers College, New Brunswick, NJ
Medical: Medical College of Pennsylvania, Philadelphia, PA Training Orthopaedic Surgery
Residency: Thomas Jefferson University Hospital, Philadelphia, PA Spine
Fellowship: Mayo Clinic, Rochester, MN
Hospital Affiliations Baylor Irving Medical Center Irving Coppell Surgical Center Irving
Offices:
Coppell :
2021 N. MacArthur Blvd 400 West IH 635 Bldg. @, Suite 115
Irving:
Plaza 1, Suite 200
Irving, TX 75061
Irving, TX 75063
Plano:
2301 Marsh Lane,
Plano, TX 75093
Certificates/Diploma’s:
Listing Details
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Lumbar Microdiscectomy, Spine Microdiscectomy, Microdiscectomy, Discectomy
The lumbar spine is the third part of the spine, after the cervical and thoracic portions. The vertebrae that comprise the lumbar spine are the largest and strongest of the three regions because they support the majority of the body’s weight. There are five pairs of lumbar nerves that control the movement and sensory functions of the lower extremities.
- Leg pain that limits your routine activities
- Weakness in your leg(s) or feet
- Numbness in your extremities
- Impaired bowel and/or bladder function
BecomePainFree has a System to perform lumbar microdiscectomy on his patients. Using this system, only the portion of a ruptured disc which is “pinching” one or more spinal nerve roots is removed.BecomePainFree begins by making a small incision in your lower back. Over this opening, he will insert a microscope that will help him clearly visualise and reach the pinched nerve. Once the pinched nerve is located, BecomePainFree will use microsurgical procedures to remove the ruptured portion of the disc and also any disc fragments which may have broken off from the main disc. The length of the procedure varies on a case-by-case basis, but generally, operative time for this surgery is less than an hour.BecomePainFree will discuss with you all risks and possible complications associated with the use of the BecomePainFree™ System, as well as the benefits. He will only perform this operation if you are a suitable candidate.
Minimal Access Spinal Technologies (MAST):
With the recent launch of Minimal Access Spinal Technologies (MAST), spine surgeons are using minimally invasive techniques for the first time to remove herniated intervertebral discs in the lumbar spine.
Minimally invasive technologies also are allowing spine surgeons to stabilize the posterior portion of the spine by making smaller incisions that cause less damage to the elements of the spine than in an “open” posterior spinal fusion.
Potential benefits of small incisions include limited tissue disruption, enhanced visualization and illumination, shorter hospital visits and faster recovery times. MAST developments continue to promote the advancement of spinal surgery, with a focus on patient recovery and new technologies and products that could potentially provide better outcomes from surgery.
BecomePainFree is committed to providing our patients with the latest advances in spinal surgery technology.
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Fax #: (888)238-9155 | E-mail Us or visit us online https://www.becomepainfree.com/
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Minimally Invasive, Endoscopic, Endoscopic Spine Surgery and Laser Spine Surgery
The trend in spine surgery has moved toward minimally invasive type procedures. Minimally invasive spine surgery (MIS) involves surgical treatment of the spine through small incisions with very minimal disruption of the surrounding muscle tissue.The benefits of minimally invasive spine surgery include decreased pain, shorter hospital stays, and quicker recovery. Come check out our large medical doctors and surgeons group at www.becomepainfree.com
Open Surgery and Minimally Invasive Surgery
Surgical procedures of the spine are often referred to as an “open back type” procedure or minimally invasive. An open procedure involves making a skin incision and retracting (moving aside) any tissues overlying the anatomy that is to be operated on so that the surgeon can directly view the desired anatomy. The surgeon will view the anatomy either with the naked eye, magnifying telescopic eyeglasses called loupes, or a magnifying microscope. Traditionally, open procedures have required larger incisions and more muscle tissue distraction than minimally invasive surgery.
Minimally invasive surgical techniques utilize specialized retractors which allow a surgical procedure to be done through smaller incisions with much less tissue disruption. One of these specialized retractors is called a tubular retractor, which is a series of gradually expanding tubes that gently and progressively dilate and separate muscles and soft tissues to expose the operative field. Using specialized instruments, surgery is performed through the tube.
Laser is one of many specialized tools that can be used during minimally invasive spine surgery. There is a common misconception that if a laser is used during surgery, no incisions need to be made. Unfortunately, this is not the case. A laser is like any other surgical tool. In order for it to be used, it has to be placed into the appropriate area of the body through an incision.
A second misconception is that lasers can be used to remove arthritis. Spinal arthritis is a condition in which the facet joints degenerate and become inflamed.Unfortunately, there is no cure for arthritis and it cannot be “lasered away”.
Finally, many people think that laser surgery is always better than surgery without a laser. Although the laser is helpful for certain procedures, not all spinal conditions can be safely or appropriately treated with a laser, and using a laser does not always provide advantages over other techniques.
Transforaminal Endoscopic Discectomy
This is a technique that is being performed by some of the surgeons at BecomePainFree.com to treat herniated discs in the lumbar spine. Transforaminal literally means “through the foramen”. The foramen is the “window” or “tunnel” through which the nerve exits from the spinal canal at each disc level. The foramen are located on the sides of the spinal canal, and provide a natural window through which the spinal canal can be accessed without having to remove any bone or ligament tissue.
The patient remains awake during the procedure. After a local anesthetic is administered, a small needle is inserted into the disc space. A 7mm (1/4 inch) “keyhole” skin incision is made and a tube is slipped over the needle into the abnormal disc. Muscle and tissue is dilated rater than being cut when accessing the disc and a laminotomy does not have to be performed. The endoscope is then inserted through the tube into the disc. Using x-ray guidance and endoscopic visualization, micro-instruments are used to remove the damaged disc. A laser may be used to further remove and shrink the disc (disc decompression) and to tighten the outer layers of the disc (annulus). On average, the procedure takes about 30 minutes to one hour per disc. Upon completion of the procedure, the probe is removed and a small bandage is applied over the incision.
Minimally invasive surgery is emerging as an alternative, reliable method of treatment for a variety of spinal disorders. Like “building a ship in a bottle”, there is a steep learning curve for surgeons learning to do these procedures. Although the recovery is often faster, the complication rate during surgery can be greater and the results may not be as predictable. Not every patient is a candidate for minimally invasive surgery.Each patient needs evaluation by a knowledgeable and experienced surgeon in this technique to determine their eligibility.
Our physicians specialize in numerous medical specialties, including, but not limited to: Orthopedics- spine and extremities, OB/GYN, Interventional Radiology, Oncology, Physical medicine and rehabilitation, Pain Management/Anesthesia, Surgical Anesthesia, Electro Diagnostic Testing, Autonomic Nervous System Testing, General Surgery/Bariatric Surgery, Hand/Plastic Surgery and Wound Care.
Call Us: (214) 396-3647 | (888) 373-3720
Fax #: (888)238-9155 | E-mail Us https://www.becomepainfree.com/
Become Pain Free, Pain, Back Pain, Spine Pain, Spine Surgery, Chronic Pain 