Neurological Surgery, P.C. Brings Progressive Spine Surgery to Long Island. Long Island

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1 Long Island A BUSINESS & PRACTICE MANAGEMENT MAGAZINE ABOUT PHYSICIANS FROM PHYSICIANS FOR PHYSICIANS Neurological Surgery, P.C. Brings Progressive Spine Surgery to Long Island

Neurological Surgery, P.C. Brings Progressive Spine Surgery to Long Island By Michael Ferguson Artem Y. Vaynman, MD, FAANS, partner and neurosurgeon, and Zachariah M.

2 Neurological Surgery, P.C. Brings Progressive Spine Surgery to Long Island By Michael Ferguson Artem Y. Vaynman, MD, FAANS, partner and neurosurgeon, and Zachariah M. George, MD, partner and neurosurgeon with Neurological Surgery, P.C. (NSPC), review films of a scoliosis patient s imaging. WHEN IT COMES TO COMPLEX SPINE SURGERY, IT S NOT ONLY THE NOVEL TREATMENT THAT MAKES THE DIFFERENCE, BUT KNOWING WHEN TO USE IT. AS ONE OF THE NEW YORK METRO AREA S LEADING PRIVATE NEUROSURGICAL GROUPS, NEUROLOGICAL SURGERY, P.C. FEATURES AN EXPANSIVE ROSTER OF EXPERIENCED, ERUDITE SURGEONS. FOR A NUMBER of spine conditions, timing is the key to treatment. Scoliosis, for example, affects as many as 6 million Americans and is responsible for more than 600,000 physician visits annually, according to the National Scoliosis Foundation (NSF). While techniques for surgical corrections have significantly improved since the days of Harrington rods, invasive procedures can be prevented altogether by early referral to a neurosurgeon at Neurological Surgery, P.C. (NSPC) for close observation and possible preventive measures. Pediatricians often note the presence of an abnormal spinal curvature and conduct customary X-rays to determine the magnitude of the deformity, says Zachariah M. George, MD, partner and neurosurgeon at NSPC. Often, the curve progresses as children experience rapid growth spurts. This is an ideal time for referral. We d like to follow any prepubescent child with spinal curvature of more than 10 degrees so we can intervene, if necessary, with bracing to prevent the need for surgery. The NSF estimates that 30,000 children require bracing each year, and as many as 38,000 require fusion surgery. Bracing is only effective before bones reach maturity, which occurs soon after the onset of puberty, according to Dr. George. Neurosurgeons may elect to brace and follow patients until spinal curves exceed 50 degrees, even when the patient is expected to experience more growth. Older patients often need surgical correction for scoliosis, says Artem Y. Vaynman, MD, FAANS, partner and neurosurgeon at NSPC. We see a lot of scoliosis in the aging population, and a recent study shows that as many as 68 percent of people 65 and older have approximately one to four degrees of scoliosis, he says.

When there s a significant spinal deformity, patients can suffer from pain in their back and legs that makes getting out of bed and walking difficult.

nerve root are not always successful. Surgical Scoliosis Correction Scoliosis commonly presents in children 10 to 15 years old and is equally prevalent in boys and girls.

3 When there s a significant spinal deformity, patients can suffer from pain in their back and legs that makes getting out of bed and walking difficult. Conservative treatments, such as physical therapy, pain medications and injections which are inherently challenging to administer with precision because the spine s curvature obscures the path to the nerve root are not always successful. Surgical Scoliosis Correction Scoliosis commonly presents in children 10 to 15 years old and is equally prevalent in boys and girls. Nevertheless, girls are eight times more likely to require surgical intervention, according to the NSF. Dr. George notes that many operations are performed to correct thoracic curvatures, and although every case is unique, the optimal operation for many is open posterior fusion. Dr. George fuses vertebrae via a bone graft, preventing bone movement and any further curvature. After correcting the deformity, Dr. George uses screw systems, hooks and hybrid constructs to hold the spine in the desired position. Using novel surgical instrumentation, Dr. George reduces the risk for blood loss and postoperative pain. Dr. George examines a patient in his Commack office. The Aquamantys System combines radiofrequency energy and saline to hemostatically seal soft tissue and bone intraoperatively. The bipolar coagulation device prevents blood loss an especially important consideration for children and older patients with cardiovascular diseases. Additionally, because fusion surgeries tend to take longer, the risk for infection can be higher. To alleviate this risk, Dr. George uses vancomycin powder in the wound. One important preoperative consideration is the presence of secondary curves that result from the body s tendency to compensate for the initial scoliotic curve. These must be identified as secondary and do not require fusing because they are not structural malformations. Rarely, patients will present with double structural curves, and in these cases, both sections of the spine require fusion. Proceeding with Care Novel approaches to fusion surgery, combined with technological innovations, make surgical intervention for scoliosis highly effective and safe. Intraoperative views from a minimally invasive correction of scoliosis performed by Dr. Vaynman We have a large practice, which allows each of us to focus on particular disease processes. Area physicians have easy access to universitylevel spine services with advanced technology in a private community setting. Zachariah M. George, MD, partner and neurosurgeon at Neurological Surgery, P.C.

WHEN YESTERDAY S GOLD STANDARD FAILS IN THE EARLY 1960s, the first surgical device for straightening and immobilizing the spine from inside the body revolutionized scoliosis repair.

I have several patients in their 40s who were treated for idiopathic scoliosis 30 years ago with Harrington rods, says Artem Y. Vaynman, MD, FAANS, partner and neurosurgeon at Neurological Surgery, P.

Because of this, they ve developed spine problems above and below the levels of the spine that were treated when they were adolescents. Revision surgeries are more complicated for a number of reasons.

4 WHEN YESTERDAY S GOLD STANDARD FAILS IN THE EARLY 1960s, the first surgical device for straightening and immobilizing the spine from inside the body revolutionized scoliosis repair. The Harrington rod remained the gold standard of scoliosis surgery until the 1980s. Problematically, the system was too successful at straightening the spine. I have several patients in their 40s who were treated for idiopathic scoliosis 30 years ago with Harrington rods, says Artem Y. Vaynman, MD, FAANS, partner and neurosurgeon at Neurological Surgery, P.C. These patients suffer from flatback syndrome, in which the spine loses its natural curvature. Because of this, they ve developed spine problems above and below the levels of the spine that were treated when they were adolescents. Revision surgeries are more complicated for a number of reasons. Scar tissue can make surgical approaches more difficult and prolong recovery times, but the failure of the vertebrae to fuse following initial intervention means that surgeons have to reconstruct the spine. You have to break the spine and rebuild it, Dr. Vaynman explains. This carries higher risks for infection, spinal cord injury and spinal fluid leakage. The challenges of revision surgery reinforce the necessity to carefully approach each initial procedure with a good plan and diligently follow patients after surgery this is why, in my fellowship, we said, You re with the scoliosis patient for life. Dr. Vaynman uses a spinal model to describe a procedure to a patient in his Rockville Centre office. Postoperative X-ray exhibiting spinal instrumentation Dr. George used to correct the deformity of a patient suffering from severe, painful kyphosis Planning software loads preoperative X-rays onto a computer and allows spine surgeons to assess the spinal anatomy and identify the necessary degrees of correction. The need for osteotomy is also gauged. At the culmination of the planning process, the software develops a prospective rendering of what the spine will look like postoperatively. At times Drs. George and Vaynman use lateral access approaches to perform minimally invasive fusion, accessing spinal deformities through the soft muscle in the patient s side. By eschewing open posterior surgeries, the surgeons reduce the need for manipulating and damaging the muscles and tendons attached to the spine. Lateral access allows us to avoid disrupting the posterior muscles, Dr. George explains. We operate anteriorly, which allows patients to maintain their native structural integrity. To correct the deformity, Drs. George and Vaynman remove the discs and straighten the spine by placing cages in the vacant space. This derotates the spine, bringing it into a more correct position. As neurophysiologists monitor nerve function, surgeons can replace as many as four discs in one procedure, according to Dr. Vaynman. For optimal screw placement, surgeons may use an intraoperative O-arm, which provides X-ray imaging at a quality comparable to that of a CT scan. The system can also be used for navigational purposes during transforaminal lumbar interbody fusion procedures, in which surgeons operate through small incisions. The O-arm can make a huge difference when dealing with very complex adult deformities, Dr. George explains. Older patients can have significant spinal rotation that makes implanting hardware and X-ray imaging challenging. We can check the implantation of instrumentation and review screw placement with the O-arm before the patient leaves the operating room, and if we find problems with any of the screws, we can remove them at that point, preventing the need for additional surgery. Full recovery can take as long as two years, but during that time, many quality-of-life-reducing symptoms

5 resolve. The process includes the following benchmarks: + + Leg pain caused by pressure on the nerve can be alleviated one day after surgery. + + Patients are out of bed and encouraged to walk the day after surgery. + + Ten days after admission, many patients are discharged. + + The rehabilitation process can last up to three weeks after surgery. + + Patients can be weaned off any narcotic pain medication after two to three weeks. + + Within six weeks, patients are often free of postoperative pain. Recent studies show that patients older than 65 with degenerative scoliosis have comparable functionality scores to patients with bilateral leg amputations, Dr. Vaynman notes. You can only imagine how dysfunctional these patients are and how much care they require. Even though spine conditions don t carry high mortality rates, my feeling is that people with these conditions don t enjoy life as much as they could. They also require a lot of care some need 24/7 supervision and assistance, and that s difficult to provide. But with a good surgical plan and early referral before they re weakened by the condition we can significantly improve these patients lives. Pressure Relief While an excellent option for scoliosis correction, fusion limits mobility and isn t ideal for all cervical spine conditions. The cervical vertebrae form the most vulnerable part of the spine. Exposing them to traumatic injury in addition to degenerative conditions such as cervical spondylotic myelopathy, a condition in which a herniated disc and/or ligamenta flava hypertrophy (ligament overgrowth) puts pressure on the spinal cord can result in the loss of function of the arms and legs and, in some cases, the bowels and bladder. Dr. George reviews treatment options with a patient. Cervical spondylotic myelopathy is a progressive disorder that patients can sometimes tolerate for years, Dr. Vaynman explains. After accommodating it for a while, patients can lose the ability to walk, hold things and coordinate function. As this happens, they begin to fall, and with each fall, the condition progresses more rapidly because the spinal cord bruises when it hits the area of compression. NSPC surgeons use different operative approaches, including fusion, discectomy and cervical laminectomy, depending on the levels of compression. Younger, healthier patients with one or two levels of compression can be treated with anterior discectomy, DYNAMIC STABILIZATION decompressing the nerve root and fusing the vertebral levels. Older patients who are in poor health and have more than three levels of compression can be treated by posteriorly removing the vertebrae and alleviating the pressure on the spinal cord. Surgeons use screws and rods to hold the spine in place. For the right patients, cervical laminoplasty is an alternative procedure that obviates the need for fusion. Not everyone who has spinal compression needs fusion, Dr. George says. The capability to perform cervical laminoplasty is important because it maintains cervical mobility lost in fusion procedures. ANOTHER ALTERATIVE TO fusion for select patients is dynamic stabilization. Younger patients who have low back pain caused by degenerative disc disease are ideal candidates for the procedure. Using screws affixed to vertebrae, surgeons use nonrigid devices to stabilize the affected area of the spine. This is a way we can stabilize patients without fusing their spine, notes Zachariah M. George, MD, partner and neurosurgeon at Neurological Surgery, P.C. The procedure helps them maintain some level of spinal mobility, which is important to people especially younger patients.

Other patients require discectomy. There s a 30 percent chance of reherniating another piece of the same disc in the six months following discectomy, Dr. Vaynman says.

6 Other patients require discectomy. There s a 30 percent chance of reherniating another piece of the same disc in the six months following discectomy, Dr. Vaynman says. After that, the risk decreases because scar tissue forms. It s imperative that after discectomy, patients adjust their lifestyle to reduce risk of herniation. If they don t lose weight and they continue smoking, the risks of reherniation increase. Artem Y. Vaynman, MD, FAANS, is ready to greet his next patient in his Lake Success office. In fact, laminoplasty preserves between 30 and 50 percent of motion at the repaired levels, according to the American Academy of Orthopaedic Surgeons. During laminoplasty, surgeons hinge open the lamina but do not completely remove the vertebrae. This provides more space in the spinal canal and provides surgeons space to repair other affected levels. Spine surgery is a considerable endeavor. However, when necessary, it should be considered sooner rather than later. There is a much better prognosis if patients are treated before they develop significant disability and muscle weakness from severe pain and lack of motion. Artem Y. Vaynman, MD, FAANS, partner and neurosurgeon at Neurological Surgery, P.C. The Lumbar Spine When an overweight patient exhibiting poor posture complains of back pain radiating down the leg, disc herniation is often the cause. Although genetic variables can play a role, most patients who suffer from disc herniations do so as a result of bad lifting techniques combined with bad posture. Many people develop the condition when the discs are ground between two bones and break, Dr. Vaynman explains. Discs don t have a mechanism for repair, and they are pushed backward, squeezing the nerve roots against bones or ligaments in the spinal canal. When that happens, patients go to their primary care provider complaining of pain in the leg. Disc herniation should be suspected if a physical exam reveals no strength deficit but patients are in a great deal of pain. MRI scans confirm the condition. At this point, either conservative or surgical interventions can be used. Conservative measures, such as physical therapy or epidural injections, can be effective 80 percent of patients resorb the herniated disc in three months, according to Dr. Vaynman. This option is particularly suited for patients who don t have laborintensive professions and can stay home while the body heals. Minimally Invasive Fusion When disc herniations occur in areas where the nerve root exits the spine, repair requires dissecting the joint connecting the two vertebrae and fusing the spine to maintain its structural integrity and prevent the likelihood of recurrent stenosis. Dr. Vaynman performs minimally invasive transforaminal lumbar interbody fusion through small incisions using tubular retractors. Instead of lifting the muscles, you spread the muscle fibers using retractors, he says. We introduce instruments through a small tube and then remove the joint and disc, alleviating the pressure on the nerve root. Through the same incision, we place bone graft and lock the two bones in place with screws and rods. Measured Care Even though surgeons at NSPC have access to the latest technological breakthroughs, the most important part of their practice is knowing the most effective conservative treatments and optimal time for surgical intervention. Patients certainly benefit from early referral, Dr. Vaynman says. Surgical repair is much more challenging when the condition has persisted for three or four years. But not every patient needs surgery. I operate on 15 to 18 percent of my patients, which is around the national average. There s not always a reason to rush someone to the operating room, but when patients make no progress after three months of conservative treatments, it s time to treat the underlying cause instead of the symptoms. For more information about NSPC, visit n Reprinted from Long Island MD NEWS

Spine Center. at Stamford Hospital s Orthopedic Institute

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