Second, the surgeon wants to achieve freedom from neurological impairment or compromise, both immediately and also in the future.

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Roland Wood
5 years ago
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1 Strange as it may seem, the objectives that a spinal surgeon wants to achieve in the treatment of spinal disorders are surprisingly few and very simple. There are only four - and in fact these are the only objectives that can be achieved. 1. Freedom From Pain First, the surgeon wants to achieve freedom from spinal pain. This is the commonest cause of trouble within the spine and is most commonly due to mechanical problems. 2. Freedom From Neurological Compromise Second, the surgeon wants to achieve freedom from neurological impairment or compromise, both immediately and also in the future. 3. Stability Third, the surgeon wants to achieve stability of the spine. 4. Make a Pathological Diagnosis Fourth, when needed, the surgeon wants to make a pathological diagnosis - is the problem mechanical, or is it for example an infection or a tumour? Treatment of the spinal disorder will then clearly involve treatment of that underlying condition as well. However, where as the objectives of surgical treatment - and its limitations - are simple, the means whereby we achieve these objectives are exceedingly complex. This is in fact the bulk of the subject matter of learned text books, which I will not attempt to reproduce here. However, it pays all - patients, even clinicians - to remember these four very simple principles. Usually, freedom from neurological compromise, spinal stability and the treatment of the underlying pathological process will result in freedom from pain. Surgical Technique 1 / 7

2 All surgery has to be carried out with meticulous surgical technique, and this is particularly true in neurosurgery. The consequences of minor lapses in technique may be tolerated in other surgical fields. In neurosurgery, they can be disastrous. Carrying out a surgical procedure falls into a number of phases: First, we obtain an informed consent. This means that the patient understands the nature of the procedure, the indications, risks, complications and the post operative care. Above all, the patient must understand that surgical procedures do not relieve all symptoms, and this must be discussed before hand. Pre-Operative Preparation Frequently, I will start patients on steroid medication just before their surgery, and continue it for a few days thereafter. Steroids have an anti inflammatory role, and can reduce swelling of the nervous system following surgery. Provided they are used in short sharp courses, the systemic ill effects are extremely rare. The commonest steroid in use in neurosurgery is Dexamethasone. Prevention Of Surgical Infection Surgical site infection remains an important source of trouble, and clearly it is a matter that causes patients a considerable amount of anxiety. I have a particularly passionate approach to surgical infection. I published a series of 176 consecutive patients who had had shunt procedures in neurosurgery. These are notorious for generating infection. In these procedures a piece of sterile tubing is inserted into the brain and it is used to divert cerebro-spinal fluid away either into the heart or into the abdomen. J Neurol Neurosurg Psychiatry 2004;75: Zero tolerance to shunt infections: can it be achieved? M S Choksey, I A Malik. In this series, I reported the lowest shunt infection rate ever recorded in the literature. We only had one infection - and it was debatable as to whether this infection had arisen in 2 / 7

3 the abdomen and tracked upwards, secondary to appendicitis. It remains one of the lowest published infection rates in the World literature. This particular series is just an index of the care that I employ when operating on patients for spinal disorders. In over 500 procedures per year, I have reduced the infection rate to 1-2 per annum. Sometimes a couple of years will go by without a single wound infection. I have never had a patient who has suffered from a deep seated infection or discitis following lumbar disc or cervical disc surgery. This record pertains both to my private and my NHS practice. I attribute the very low infection rate to a strict adherence to what I term as the " five A's" 1. Asepsis The prevention of bacterial infection of the wound. It is the underlying principal of what one might term "theatre ritual" - the meticulous cleaning of the skin, the draping of the patients, insuring a wide sterile field and above all maintaining a ruthless discipline amongst the operating staff. 2. Antisepsis It has my practice for many years to use antiseptics within the wound. As soon an incision is made, I fill the wound with antiseptics - (usually Betadine or Chlorhexidine if the patient has an allergy). 3. Antimicrobials The use of antimicrobials is now widespread in all branches of surgery, and neurosurgery is no exception. For my regime I am indebted to Dr Harry Ingham, who was Consultant Microbiologist 3 / 7

4 at the Newcastle General Hospital, whilst I was there in the latter stages of my training. I have used Penicillin and Flucloxicillin as standard antimicrobials, or Rifampicin and Teicopanin if the patient is allergic to penicillin. The most important thing about antimicrobials in surgical prophylaxis is they must be given at the time of anaesthetic induction, so that they are distributed within the wound at the time that this incision is made. It is my practice to continue with antimicrobials for 48 hours if the patient is undergoing non-implant surgery, or 5 days if they have an implant. 4. Avoid Haematomas A blood clot within a wound is a perfect culture medium. Antimicrobials do not really diffuse into it, and the breaking down protein and red cells are a perfect substrate for bacterial growth. Therefore, it is my practice to drain practically all surgical wounds, except the most trivial. 5. Careful Apposition Of The Skin The skin is a very potent barrier against infection. If it is apposed carefully in many layers, and then a sterile dressing over it, and that dressing is kept dry for 7 days, the ingress of bacteria seems to be negligible, and wounds do not become..infected. Other Complications Of Surgery Post operative bleeding is a particular complication in neurosurgery which we do our utmost to avoid. Wound drainage has a role to play but the most important aspect of post operative haematoma avoidance is meticulous haemostasis. Bleeding after surgery can compress the spinal cord and nerves, causing pain, then rapidly tingling, numbness and weakness. Watching for clinicl symptoms and signs of post-operative bleeding is the prime purpose of close observation, particularly during the night after surgery. Cerebro Spinal Fluid (CSF) Leaks Cerebro spinal fluid leaks through an inadvertent puncture of the dura can occur. These are very rare, particularly if they are identified at the time of surgery. I have only had three patients who have developed cerebro spinal fluid leaks through the wound in over 9000 neurosurgical spinal procedures over 16 years at the University Hospital and the Warwickshire Nuffield Hospital Nerve Damage 4 / 7

5 Clearly, at the time of neurosurgical procedures, one is handling nerves. Unfortunately, every so often, despite exquisite care with handling, nerves will be damaged. It is extremely rare physically to cut through a nerve. However, even retracting these nerves can lead to dysfunction. Very frequently this is temporary, and amounts to nothing more than some sensory loss (numbness over an arm or a leg). My personal record is good in this regard - the instance of nerve damage in my hands is less than 1 in With regards to spinal cord damage, it remains nil, in over 1000 procedures on the cervical spinal cord (in the neck). Deep Vein Thrombosis and Pulmonary Embolus These are serious consequences of any form of surgery. Any period of immobilisation can lead to clotting of blood in the great veins of the leg, and these blood clots at the worst can break off and cause obstruction to blood flow to the heart and lungs. This can result in severe problems within the lungs or even death. In modern surgery we do everything we can to prevent these dreadful complications. Pre operatively, all patients are fitted with anti thrombo-embolism stockings. During the operation we use Flowtron boots, which squeeze the legs and help return the blood to the heart. We minimise the time for which the patient is kept asleep and anaesthetised. Then we mobilise patients (get them walking) as soon as possible. Finally, I use Clexane (a blood thinning agent) after surgery when I am happy that the risk of bleeding has fallen to a very low and acceptable level. Implant Failure Modern implants are tested to a very high degree before they are implanted into patients. Even so, rarely metal work can fail. It can also loosen and slip. With my lumbar spinal fixation regime using Xia screws and OIC cages, made by Stryker, I have not had a single graft failure or migration in over 300 lumbar spinal fusion operations. In terms of screw placement, I have placed over 1400 pedicle screws, and have had one migrate through the pedicle medially. 3 pedicles have cracked: however, there has never been a single incidence of nerve damage or cerebro-spinal leak as a result of pedicle screw placement in my practice. I attribute this to meticulous preoperative planning, including measurements of the lumbar vertebrae prior to inserting the pedicle screws, so that their trajectory can be predicted well in advance. There are illustrations of this in the section on lumbar spine fixation. 5 / 7

Major Vascular Injury From Anterior Spinal Injury It is common neurosurgical practice now to replace all fused discs in both the cervical and lumbar spine from the front.

6 Major Vascular Injury From Anterior Spinal Injury It is common neurosurgical practice now to replace all fused discs in both the cervical and lumbar spine from the front. Whereas anterior cervical spinal surgery is well established as a solely neurosurgical procedure, because retracting the great vessels of the neck is relatively simple, the same cannot be said of lumbar spinal surgery or thoracic spinal surgery. Here, retracting the great vessels and obtaining access to the disc is quite complex. 6 / 7

7 I have carried out over 100 anterior lumbar spinal procedures, and every one of them has been done with the help of a very experienced vascular surgeon. Initially, I carried these out with Mr Peter Roberts, my most esteemed recently retired colleague. More recently, Professor Christopher Imray and I have worked together as a team. It is my personal opinion that all anterior spinal neurosurgical procedures which involve retraction of the great vessels should be done jointly with the vascular surgeons: it is not sufficient merely to have one "standing by". I would admit to being highly conservative and cautious in my approach, but to date it has paid dividends for my patients. Following this preamble, I have discussed specific surgical approaches in a number of common conditions which I treat: Surgical Procedures 7 / 7

Posterior Lumbar Spinal Fusion

Posterior Lumbar Spinal Fusion Information to help patients prepare for a Posterior Lumbar Spinal Fusion Operation Directorates of Orthopaedic and Rheumatology, and Neurosciences Produced: February 2007