Procedures
Dr. Moreno has been in private practice since 1998 and treats a wide variety of spine disorders such as scoliosis and deformity, kyphosis, neck pain, back pain, cervical spine disorders, degenerative disc disease, degenerative spinal conditions, herniated disc, lumbar spine disorders, spinal stenosis, spondylolisthesis, and thoracic spine disorders.
Dr. Moreno treats these conditions with many different techniques inlcuding: discectomy, TLIF, kyphoplasty, microdiscectomy, scoliosis surgery, spinal fusion, and vertebroplasty. Information about many of these procedures is found below. For additional information about these conditions, visit the following websites:
Anterior Cervical Fusion
Anterior cervical spinal fusion surgeries are commonly done in conjunction with an anterior cervical discectomy. For many patients, cervical spinal fusion surgery (fusing one vertebra to another) is often done to eliminate motion at a vertebral segment. Decreasing the motion at a painful motion segment should decrease the pain at that segment. Achieving the fusion also serves to maintain adequate space for the decompressed spinal cord and/or nerve roots. The fusion may also prevent the spine from falling into a collapsed deformity (kyphosis).
Additionally, anterior cervical spinal fusions are also done to treat cervical instability due to:
Trauma (fractures or dislocations)
Tumor
Infection
Bone grafts for spinal fusion surgery
To achieve a spinal fusion, a bone graft is used to promote two bones growing together into one. The patient’s own bone will grow into and around the bone graft and incorporate the graft bone as its own. This process creates one continuous bone surface and eliminates motion at the fused joint. A small piece of bone is used to fuse a disc space, and a longer so-called ‘strut graft’ is used to bridge across multiple disc spaces if a ‘corpectomy’ has been performed.
For more information, visit www.spine-health.com
Cervical Disc Replacement
Artificial cervical disc technologies are being developed in an effort to treat symptomatic degenerative disc disease more effectively. The main goal of this type of technology is to maintain spinal motion following anterior discectomy, to reduce the incidence of degeneration of adjacent disc levels of the spine (adjacent-segment disease), and to permit more rapid return to normal activity.
Surgical procedure for cervical disc replacement
The standard surgical procedure for a disc replacement is an anterior (from the front) approach to the cervical spine. This surgical approach is the same as that presently used for a discectomy and fusion operation. The affected disc is completely removed including any impinging disc fragments or osteophytes (bone spurs). The disc space is distracted (jacked up) to its prior normal disc height to help decompress (relieve pressure) on the nerves. This is important because when a disc becomes worn out, it will typically shrink in its height, which can also contribute to the pinching on the nerves in the neck.
At this point, using x-rays or fluoroscopy, the artificial disc device is implanted into the prepared disc space. Postoperatively, the patient typically can go home within 24 to 48 hours with minimal activity limitations.
Potential risks and complications
The potential complications with an artificial device are at least similar to an anterior cervical discectomy and fusion and may include:
• Infection
• Blood loss
• Nerve injury or paralysis
• Need for further surgery
Although these complications can be severe, they are very rare occurrences.
In addition, the artificial disc does theoretically have some of the same potential complications associated with total hip and knee arthroplasty. An arthroplasty is a mechanical device and by the laws of physics will wear out over long periods of time. That time period remains to be defined for total disc replacement. In addition, small particle debris may react with the body. Laboratory and animal studies for some of the devices have shown that after simulating ten years of wear, only minimal disc wear occurs and the materials appear to be well tolerated over time.
Epidural Steroid Injections
Spinal injections are not new – the use of spinal injections to treat low back pain was first documented in 1901, and in 1952 epidural steroid injections were first used to treat low back pain with associated sciatica (pain in the sciatic nerve due to lumbar disc herniation). Today, epidural steroid injections have become an integral part of non-surgical management of low back pain.
Several common conditions—including a lumbar disc herniation, degenerative
disc disease, and lumbar spinal stenosis—can cause severe acute or
chronic low back pain and/or leg pain. For these and other conditions that
can cause chronic pain, an epidural steroid injection may be an effective
non-surgical treatment option. While the effects of the injection tend to be temporary
- providing relief from pain for one week up to one year - an epidural can
be very beneficial for patients during an episode of severe back pain. Importantly,
it can provide sufficient pain relief to allow the patient to progress with
their rehabilitation program.
An epidural is an injection that delivers steroids directly into the epidural space in the spine. Sometimes a flushing solution (either lidocaine or normal saline) is also used to help "flush out" inflammatory proteins from around the area that may be the source of pain. The epidural space is the space between the dura mater (a membrane) and the vertebral wall and is filled with fat and small blood vessels. It is located just outside the dural sac. The dural sac surrounds the nerve roots and cerebrospinal fluid (the fluid that the nerve roots are bathed in).
An epidural steroid injection usually takes between 15 and 30 minutes. The patient lies flat on an x-ray table on their abdomen. Prior to the epidural injection, the skin is numbed with lidocaine, which is similar to the novocaine that the dentist uses (a "local" anesthetic).
Many types of physicians
can be qualified to perform an epidural steroid injection, including an anesthesiologist,
radiologist, neurologist, physiatrist and surgeon. Using fluoroscopy (live
x-ray) for guidance, the physician directs a needle toward the epidural space.
Fluoroscopy is considered important in guiding the needle into the epidural
space, as controlled studies have found that medication is misplaced in 13%
to 34% of epidural steroid injections that are done without fluoroscopy.
Once the needle is in the exact position, the epidural steroid solution is
injected. Following the injection, the patient is usually monitored for 15
to 20 minutes before being discharged to go home.
For more information, visit www.spine-health.com
Kyphoplasty
The traditional treatment for fractures of the spine caused by osteoporosis has included pain reduction (medication), bed rest and bracing. In 1984, a surgical technique designed to reduce the pain and loss of function called "Percutaneous Vertebroplasty" was developed in France. In 1998, the Food and Drug Administration cleared a special balloon, the KyphX Inflatable Bone Tamp, for use in reducing (setting) fragility fractures to help them heal and creating a cavity in the soft inner bone in the vertebral body.
Over 195,000 fractures have been treated with balloon kyphoplasty as of October 31, 2005, and approximately 7,400 physicians worldwide have been trained to do the procedure.
Osteoporosis—the loss of calcium from bones resulting in weakened bone structure—increases the risk of fracture of vertebral body (the thick block of bone at the front of the vertebrae). In this type of fracture, the top of the vertebral body collapses down with more collapse in front thus producing the "wedged" vertebrae, the "dowagers" hump and shortened height
The resulting change in height and spinal alignment can lead to serious health problems, including:
Chronic or severe pain
Limited function and reduced mobility
Loss of independence in daily activities
Decreased lung capacity
Difficulty sleeping
Also, studies show that a first osteoporotic fracture makes it five times more likely further fractures will occur. That is why it is important that patients seek medical treatment for osteoporosis before it reaches the fracture stage.
Kyphoplasty compared with vertebroplasty
Vertebroplasty and kyphoplasty are both minimally invasive surgical procedures
for treating osteoporotic fractures where a cement-like material is injected
directly into the fractured bone. This stabilizes the fracture and provides
immediate pain relief in many cases.
Kyphoplasty includes an additional step. Prior to injecting the cement-like material, a special balloon is inserted and gently inflated inside the fractured vertebrae. The goal of this step is to restore height to the bone thus reducing deformity of the spine. Most patients return to their normal daily activities after either procedure.
For more information, visit www.spine-health.com
Kyphosis Correction
Scheuermann's disease is a developmental disorder that causes patients to have a stooped forward or bent-over posture as a result of excessive kyphosis of the thoracic spine. This condition affects between 0.5% and 8% of the general population, and is more common in boys than in girls. Scheuermann's disease is caused by more than bad posture, and there are several clinical and radiographic findings that are typical in this disease that help to differentiate Scheuermann's kyphosis from postural kyphosis.
Diagnosis
The diagnosis of Scheuermann's disease is made on the basis of a physical examination and radiographs of the spine. A physical examination is used to determine where the apex of the curve is located, where the patient is experiencing back pain, how flexible the curve is, and whether or not there are any other related findings. Currently, the most commonly accepted criteria for the radiographic diagnosis of Scheuermann's disease is the presence of at least 5 degrees of vertebral body wedging over three adjacent levels. Radiographs are also used to determine more precisely the relative percent correction that is possible by attempting to reverse the kyphotic curve with a bolster or a pillow placed at the apex of the curve while the patient is lying down.
Treatment
The treatment of Scheuermann's disease depends upon several factors, including the age of the patient, the severity of the curve, the presence or absence of back pain, and whether or not the lungs are developing and functioning normally.
If a patient is young, has a mild curve, no back pain, and normal pulmonary function, then continued observation by a doctor is usually prescribed, with repeat clinical examinations and radiographs at regular intervals (often every year). Many doctors will advise patients with kyphosis to participate in activities that strengthen the muscles that support the spine, stretch the hamstrings, and improve cardiovascular fitness. This type of therapy is considered an important part of ensuring the curve stays as flexible as possible, and that the muscles of the back are as strong as possible in an effort to prevent further progression.
Other forms of treatment, including bracing and surgery, are considered when there is a rapid increase in the size of the curve; worsening of the vertebral body wedging, back pain that will not improve with conservative measures, and difficulties with pulmonary function that are related to the kyphotic deformity. The decision about when and how to brace the spine of a patient with Scheuermann's disease, or to perform surgery, is made on an individual basis.
For more information, visit www.back.com
Lumbar disc Replacement
There are a wide variety of new products, procedures and techniques currently in development to enhance spine surgery, and many spine surgeons believe that artificial disc technology holds real promise for significantly improving the standard of care for many patients. Published study data from the Charite trial, as well as interim comparative data from the larger ProDisc investigational study centers demonstrate improved VAS and Oswestry functional scores in arthroplasty patients, and suggest earlier return to work with better lumbar motion as compared to the control fusion group.
Traditionally, spinal fusion surgery (rather than artificial disc surgery) has been the treatment of choice for individuals who have not found pain relief for chronic back pain through conservative treatment (such as physical therapy, medication, manual manipulation, etc), and have remained disabled from their occupation, from their activities of daily living, or simply from enjoying a relatively pain-free day-to-day existence.
In the United States, over 200,000 spinal fusion surgeries are performed each year. While there have been significant advances in spinal fusion devices and surgical techniques, the procedure does not always work reliably. For example:
In a review of 4,454 patients in 78 reports, Bono and Lee found the average fusion rate was 85%, and the average clinical success rate (pain reduction) was 75%. They also found that a successful spinal fusion takes a relatively long time (3-24 months, average 15 months) for healing and recuperation, and causes adverse effects on adjacent levels over time.
Premature degeneration at adjacent levels of the spine (Transition Syndrome) remains one of the more vexing problems facing spinal surgeons when advising relatively young people to consider lumbar fusion surgery.
For more information, visit www.spine-health.com
Lumbar Fusion
Spinal fusion surgery is designed to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. All lumbar spinal fusion surgery involves adding bone graft to an area of the spine to set up a biological response that causes the bone graft to grow between the two vertebral elements and thereby stop the motion at that segment.
For patients with the following conditions, abnormal and excessive motion at a vertebral segment may result in pain:
• Degenerative disc disease
• Isthmic, degenerative or postlaminectomy spondylolisthesis.
Other conditions that may be treated by a spinal fusion surgery include a weak or unstable spine (caused by infections or tumors), fractures, scoliosis or deformity.
How spine fusion surgery works At each level in the spine, there is a disc space in the front and paired facet joints in the back. Working together, these structures define a motion segment and permit multiple degrees of motion. Two vertebral segments need to be fused together to stop the motion at one segment, so that an L4-L5 (lumbar segment 4 and lumbar segment 5) spinal fusion is actually a one-level spinal fusion.
A spine fusion surgery involves using bone graft to cause two vertebral bodies to grow together into one long bone. Bone graft can be taken from the patient's hip (autograft bone) during the spine fusion surgery, or harvested from cadaver bone (allograft bone). Synthetic bone graft substitutes are also in development, and one type—bone morphogenic proteins (which helps the body create bone)—is currently being used for certain fusion procedures.
In general, a lumbar spinal fusion surgery is most effective for those conditions involving only one vertebral segment. Most patients will not notice any limitation in motion after a one-level spine fusion. Only in rare cases should a three (or more) level fusion surgery for pain alone be considered, although it may be necessary in cases of scoliosis and lumbar deformity.
When necessary, fusing two segments of the spine may be a reasonable option for treatment of pain. However, spinal fusion of more than two segments is unlikely to provide pain relief because it removes too much of the normal motion in the lower back and places too much stress across the remaining joints.
For more information, visit www.spine-health.com
Lumbar Microdisectomy
Lumbar microdiscectomy is an operation on the lumbar spine performed using
a surgical microscope and microsurgical techniques. A microdiscectomy requires
only a very small incision and will remove only that portion of your ruptured
disc which is "pinching" one or more spinal nerve roots. The recovery
time for this particular surgery is usually much less than is required for
traditional lumbar surgery.
Lumbar microdiscectomy is usually recommended only when specific conditions
are met. In general, surgery is recommended when a ruptured disc is pinching
a spinal nerve root(s) and you have:
Leg pain which limits your normal daily activities
Weakness in your leg(s) or feet
Numbness in your extremities
Impaired bowel and/or bladder function
In the operating room, a lumbar microdiscectomy begins with a small incision
in your lower back. Through this opening, your surgeon will insert microsurgical
instruments. Because the work is viewed through a microscope, this approach
requires a relatively small incision.
Guided by diagnostic studies, your surgeon will remove a small portion of bony material from the back of your vertebra. Once this material is removed, the surgeon can locate the exact area where the nerve root is being pinched.
Once
the "pinched" nerve is located, the extent of the pressure
on the nerve can be determined. Using microsurgical procedures, your surgeon
will remove the ruptured portion of the disc and any disc fragments which
have broken off from the main disc. The amount of work required to complete
your microdiscectomy will depend in part on the number of disc fragments
present and the difficulty presented in finding and removing them.
The operation is completed when each layer of the incision is closed with
suture material (stitches) or surgical staples. If the outer incision is
closed with staples or non-absorbable sutures, they will have to be removed
after the incision has healed.
For more information, visit www.back.com
Osteotomy
When a bone needs to surgically cut or broken, this is called an osteotomy. In the spine, an osteotomy is sometimes performed to create motion between segments of the spine in order to correct a deformity. Another reason for an osteotomy may be to remove a block of bone that obstructs the spinal canal or requires removal for clearer visualization of nerves or other structures around the spine.
Posterior Cervical Microdisectomy
Some spine surgeons may prefer the posterior approach (from the back of the neck) for a cervical discectomy. This approach is often considered for large soft disc herniations that are lateral to (to the side of) the spinal cord.
The principal advantage of the posterior approach is that a spine fusion does not need to be done after removing the disc.
The principal disadvantage is that the disc space cannot be jacked open with a bone graft to give more space to the nerve root as it exits the spine. Also, since the posterior approach leaves most of the disc in place, there is a small chance (3% to 5%) that a disc herniation may recur in the future.
The general procedure for the posterior cervical decompression (microdiscectomy) surgery is:
1. Surgical approach: A small incision is made in the midline of the back of the neck. The para-spinal muscles are elevated off the spinal level that is to be approached.
2. Disc removal: An x-ray is done to confirm that the surgeon is at the correct level of the spine. A high speed burr is used to remove some of the facet joint, and the nerve root is then identified under the facet joint. An operating microscope is then used for better visualization. The disc will be directly under the nerve root, which needs to be gently mobilized (moved to the side) to free up the disc herniation. There is usually a plexus (network) of veins over the disc that can obstruct visualization if they bleed.
For more information, visit www.spine-health.com
Scoliosis Correction
Treatment for scoliosis is based on the skeletal maturity of the
patient, that is, how much more the patient is
expected to grow, as well as on the degree of curvature. The younger
the patient and the bigger the curve, the
more likely the curve is to progress.
For patients with idiopathic scoliosis, there are three options for
treatment. These options are observation, bracing,
and surgery. Many other forms of treatment have been tested, including
electrical stimulation, physical therapy,
and various manual manipulation techniques, but none have been proven
to be effective.
Conservative (non-surgical) treatments
The degree of curvature is
measured on x-rays by what is known as the Cobb method, and this
is accurate to within 3 to 5 degrees.
In cases of curves that are less than 10 degrees, there is very little chance of the condition getting any worse. In fact this isn’t even considered to be scoliosis, but instead is spinal asymmetry. Most of the time these cases won’t require any treatment, but at regular physician check-ups throughout childhood the physician should determine whether or not the curvature has progressed at all.
Curves that are 20 to 30 degrees in a growing child should be checked every 4 to 6 months to see if they are worsening. Any curves over 30 degrees in a growing child will require treatment, usually in the form of a back brace. Using a brace is intended to stop the growth of a curve, but will not correct the degree of curvature that already exists. The use of the brace is discontinued when the child stops growing.
Patients with curves of greater than 50 degrees sometimes continue to progress after the child’s growth has stopped. Therefore the objective of any treatment is to get the child into adulthood with less than a 50 degree curvature.
There are two types of commonly used braces. One is worn almost all day and night, but can be taken off for swimming or playing sports. This brace applies three-point pressure, and prevents the progression of the curvature. The other applies more pressure and bends the child against the curve. It is worn only at night while the child is sleeping.
Unfortunately, some curves continue to progress even with appropriate bracing. This may lead to the child needing more aggressive, surgical treatment. In some cases the physician will continue bracing the spine for a period of time, to allow the child to grow more before moving to the surgery option, which fuses the spine.
Surgical treatments
For patients with a 40 to 45 degree curve that
is still progressing, or a curve of 50 degrees or more, surgery will
likely be recommended. The objective is to fuse the spine
in a more corrected position so that the curve will not
continue to progress into adulthood. In addition to preventing
further curvature, scoliosis surgery can also reduce
the amount of deformity. Rods, cables, screws and hooks are
used to move the spine back into the proper
position, and when the spine fuses with the bone grafts it
no longer moves out of place. Although the rods can be
removed once the spine has fused, there is usually no reason
to do so. Typically a correction of about 50% can
be obtained with this method.
Patients should be regularly monitored for the first year or two. Once the bone is solidly fused there is no need for further treatment. In general, patients undergoing this surgery can return to a normal lifestyle and activity level.
For more information, visit www.spine-health.com
Spinal Fusion Surgery
A spinal fusion is simply the uniting of two bony segments, whether a fracture
or a vertebral joint. The reason for instrumentation with rods and screws
is to act as and 'internal cast' to stabilize the vertebra until the fusion,
or bony re-growth, can occur.
Historically spinal fusions have been used to correct degenerative spondylolisthesis.
However, there are many indications for a spinal fusion and it is not the
only procedure preformed to treat those various conditions. You should talk
to your doctor about what procedure is best for you.
For the operation, the patient is positioned on the operating table in a prone position. The incision is made over the anatomic position of the spinous process. When indicated, soft tissue and bony decompression are performed to relieve neurological compression.
For a degenerative spondylolisthesis case, a blunt probe is inserted through
the pedicle and into the vertebral body. Once the pedicle canals are prepared
and the screw length determined, the screws are sequentially inserted.
The facet joint capsules are removed and cancellous bone graft is placed
into each facet joint. The transverse processes, sacral alae, and the lateral
walls of the facet joints are decorticated with high-speed burs and curettes.
Corticocancellous bone graft taken from the iliac crest, along with any fragments
of bone taken during decompression are firmly pressed into the bone fusion
bed.
Once the construct has been assembled, segmental distraction and compression may be carved out. Then a final tightening is performed. The incision is closed in the traditional fashion.
For more information, visit www.back.com
Transforaminal Lumbar Interbody Fusion (TLIF)
Transforaminal Lumbar Interbody Fusion (TLIF) is an operation where the
lumbar spine is approached from the side through an incision in the back.
A portion of bone and disc are removed from the spine and replaced with an
implant that is inserted into the disc space. Titanium or stainless steel
screws and rods are inserted into the spine to ensure the stability of the
entire construct.
Patients who are suffering from back and/or leg pain are potential candidates
for the TLIF procedure. The causes of the pain may range from a natural degeneration
of the disc space to some type of traumatic event.
The operation is performed with the patient laying on his or her stomach.
An
incision is made in the patient's back to allow the surgeon access to the
spine. The surgeon separates the muscle and tissue to be able to have a clear
view of the spine. Once the spine is in view, the surgeon will remove a portion
of bone from the appropriate areas of the spine to allow the surgeon to access
the disc space. The surgeon will remove the disc material to allow the surgeon
to insert an implant into the disc space.
The surgeon will also insert titanium or stainless steel implants into the
spine. The implant and the screws will help to restore the spine back to
its normal anatomic condition.
After the surgery, the patient will normally stay in the hospital between
3-5 days. The specific time of stay in the hospital will depend on the patient
and the surgeon's specific post-operative surgical plan. The patient will
normally be up and walking in the hospital by the end of the first day after
the surgery. Your surgeon will have a specific post-operative recovery /
exercise plan to help you return to normal life as soon as possible.
For more information, visit www.back.com
