Procedures San Francisco
Laminoplasty is a non-fusion, motion-preserving cervical procedure performed from the back (posterior approach). It was pioneered in Japan by Hirabayashi about three decades ago for the treatment of cervical spinal cord compression caused by ossification of the posterior longitudinal ligament. Since then, it has been used for more typical arthritic conditions as seen in the Western world—namely, cervical spondylotic myelopathy or compression of the spinal cord due to arthritis (degenerative disc disease). It involves hinging the lamina (roof of the spinal canal) in the cervical spine open and holding it open with little titanium mini-plates. The mini-plates do not bridge several levels; therefore, it is not considered a fusion procedure. Intraoperatively, we do utilize a surgical microscope, and for cases of severe myelopathy, we utilize neurological monitoring to ensure absolute neurological safety. Postoperatively, patients usually require use of a hard collar for anywhere from a few days to up to two weeks; however, long-term bracing usually is not indicated. Initially, laminoplasty was utilized by Hirabayashi in Japan for treatment of cervical OPLL (ossification of the posterior longitudinal ligament); nowadays it is used for treatment of a variety of other conditions, including cervical spondylotic myelopathy (arthritic compression of the cervical spinal cord). The surgery takes anywhere from two to four hours, and a hospital stay normally is anywhere from two to five days.
Fusion is a tool that is utilized in spine surgery to join several vertebrae together. It is a common procedure that has been used since 1911 for treatment of a variety of spinal conditions, including degenerative conditions, deformity (scoliosis and kyphosis), infections, tumors, and congenital and inflammatory conditions. Historically, the fusion process frequently involves placing instrumentation into the spine—for example, pedicle screws in the thoracolumbar spine for an operation done for the back (posterior approach), lateral mass screws in the cervical spine (for posterior approach). The screws are anchors grabbing onto particular vertebrae, and they have to be connected to another anchor (another screw at a different level), usually with a small rod. The materials that are used for instrumentation in spine surgery are either pure commercial titanium (PCT), titanium alloy, stainless steel, or cobalt-chrome alloy. Depending on the situation, the surgeon may choose to utilize one or a combination of the above. Also, another frequently used biomaterial is PEEK (polyether ether ketone), which is used mostly for interbody devices such as ALIF, TLIF, PLIF, and XLIF cages. The screws connected by rods serve as an internal bracing or scaffold, which allows for the spine to fuse while maintaining the appropriate alignment. In essence, the function of the screws is temporarily holding the spine while the fusion takes its place. The fusion process—depending on the situation, age of the patient, and the number levels treated—can take anywhere from three to 24 months. In this sense, the function of the screws is usually temporary; however, in the majority of cases, after the fusion is completed, the screws stay in place. The majority of patients do not feel the screws (so-called hardware), and therefore additional operation to remove the screws is not warranted. However, very infrequently, some patients do feel the screws and require hardware removal.
Keyhole Foraminotomy (Laminoforaminotomy)
A cervical (neck) procedure to decompression a pinched nerve. It is used instead of anterior cervical discectomy and fusion. The advantage is that it is a motion-preserving procedure and can be done in a minimally invasive fashion. (MIS surgery can be done as an outpatient.) The caveat is that it only can free one nerve on one side, so if the patient has compression of two nerve roots at two distinct levels, then usually this will not be the best procedure. Also, if the patient has a significant neck pain (axial neck pain), usually we opt to go for a more definitive procedure such as a fusion. In general, for isolated cervical radiculopathy (pain of a pinched nerve), this is a great option if the nerve compression is off to the side. If the nerve compression is more in the middle, then usually fusion is a better option. This is a fairly old procedure that has been used for a half a century or so in conjunction with anterior cervical discectomy and fusion to address similar pathology. The results in general are quite favorable and pretty comparable to fusion. Once again, the main advantage is that it avoids the fusion and theoretically avoids changing the biomechanics of the adjacent segment.
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