Long Island A Business & Practice Management Magazine about physicians from physicians for physicians Unlocking the Anatomy of the Spine: Minimally Invasive Techniques at Neurological Surgery, P.C. The field of spinal surgery has significantly evolved since French physician Nicolas Andry published his tome, Orthopaedia, on correcting deformities in children in 1741. Today, Long Island patients can access a myriad of modern developments from image-guided spine surgery to posterior lumbar interbody fusion delivered by modern-day experts at Neurological Surgery, P.C. Matthew B. Kern, M.D., neurosurgeon at Neurological Surgery, P.C., at his desk in his Port Jefferson, NY, office Spinal surgery in the 20th century revolved around a singular approach to targeting deformities, degenerations, and injuries of the spinal cord and individual vertebrae through the back. According to Matthew B. Kern, M.D., neurosurgeon at Neurological Surgery, P.C., diseased vertebrae located in the anterior section of the spine were once almost inaccessible or only reachable through very complex posterior approaches. In the 1950s and 1960s, the introduction of cervical approaches widened the options available to both patients and surgeons. Dr. Kern explains that the 1970s and 1980s brought the first spinal surgery instrumentation, starting with posterior Harrington rods. These early devices gave way to Cloward Dowel instruments for the cervical spine and then the first spine plate implant, the Caspar Spine Plate. Over the ensuing years, the basic concepts of how to fixate the spine so it maintained biomechanical stability, as well as the integrity of the spine s balance, have improved techniques to the point that we now have a multitude of ways of approaching the spine, says Dr. Kern. The other components that have changed dramatically especially in the last two decades are the materials we now use for spinal implants. These developments have paved the way for the cutting-edge techniques and approaches utilized by neurosurgeons at Neurological Surgery, P.C., including
Matthew B. Kern, M.D., places a METRx System tube to dilate the fascia using fluoroscopic guidance. advanced treatments for spinal concerns such as injection therapy and minimally invasive surgical intervention. Tailored to the Case The majority of patients who come to the practice are referred by their primary care physicians, who may have already progressed patients through a course of general, conservative treatment and education. The consensus within the primary care community, as published in the Journal of General Internal Medicine, is that referral to a specialist for back pain is appropriate when symptoms do not improve over the course of four to six weeks. Upon their first visits to Neurological Surgery, P.C., patients complete a history information form detailing their chief complaints and the lengths of time they have experienced pain. As Dr. Kern explains, the physician conducting the initial visit specifically looks for any signs of weakness and numbness as opposed to pain presenting on its own. A Neurosurgeon s Calling One of 12 spine specialists at Neurological Surgery, P.C., Matthew B. Kern, M.D., neurosurgeon, combines general neurosurgery practice with expertise in complex spinal surgery and surgical intervention for brain tumors and traumatic injuries of the brain, spine and spinal cord. Dr. Kern earned his medical degree at the University of Medicine and Dentistry of New Jersey New Jersey Medical College and later completed a surgical internship and a one-year residency in general surgery at Newark s University Hospital. He then completed a research fellowship and a two-year residency in neurosurgery in New Jersey, followed by another two-year neurosurgery residency in Albuquerque, NM. Dr. Kern also served a year as chief resident of neurological surgery. Returning to the East Coast, Dr. Kern joined Neurological Surgery, P.C., in fall 2011 after having been in private practice in Evansville, IN, for 14 years. In addition to managing the neurological needs of his own patients, he was heavily involved in securing Level II Trauma Center status for St. Mary s Medical Center, also located in Evansville. He held the post of chief of adult and pediatric neurosurgery for seven years following the accreditation. Dr. Kern, who maintains membership with both the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, has served in the U.S. Army Reserve for 18 years. He holds the rank of lieutenant colonel and has completed two overseas deployments. At Neurological Surgery, P.C., Dr. Kern offers Long Island patients artificial cervical and lumbar disc arthroplasty and minimally invasive spinal services, as well as dorsal column stimulation and peripheral nerve surgery.
METRx System tube in place in paraspinal location photos Don Dempsey, White Light Photography The evaluation also includes a thorough physical examination and a review of any completed radiographic studies. Further imaging may be ordered when necessary. All three components contribute to the subsequent formulation of a treatment plan. In many cases, patients can be progressed through conservative care, such as physical therapy, chiropractic care and injection therapy. The latter can be performed at Neurological Surgery, P.C. and targets pain through localized injections to the individual joints or blocks to particular nerves. These include facet joint, lumbar epidural steroid and sacroiliac joint steroid injections and lumbar sympathetic blocks. A facet joint injection serves as both a diagnostic tool to accurately determine a patient s source of back and neck pain, and as a therapeutic treatment, offering patients pain relief. For this procedure, a physician administers a dose of anti-inflammatory steroid medication mixed with an anesthetic to the area under fluoroscopic guidance. A lumbar epidural steroid injection targets the epidural area located between the L-4 and L-5 vertebrae with a similar medication delivered to the nerve root by needle. The sacroiliac joint steroid injection offers the same kind of treatment for the joint connecting the pelvis and sacrum. Finally, to address leg pain related to complex regional pain syndromes, a lumbar sympathetic block involves administering anesthetic, anti-inflammatory medication and saline to the sympathetic nerves in the lumbar spine to block pain signals traveling to the brain. Certain situations and presentations, however, require Dr. Kern and his colleagues to bypass conservative treatment and proceed directly to surgery. These cases include cervical spondylotic myelopathy, components of stenosis such as facet hypertrophy and ligamentum flavum hypertrophy, degenerative disc disease, dropped foot, instability of the spine, a large cervical herniated disc accompanied by weakness in the arm, and spondylolisthesis with severe stenosis, in addition to emergency trauma cases. The Single-Level Solution Both cervical and lumbar back pain involving a single level of the spine can be addressed with an artificial disc arthroplasty. Traditionally, patients with single-level related disease were offered fusion surgeries. Those procedures, such as the posterior lumbar interbody fusion, allow surgeons to place a bone graft between two vertebrae to stimulate growth in that space, which can eventually impede the spine s range of motion in that area. Artificial disc arthroplasty relieves pain stemming from pinched nerves and addresses the underlying mechanical concerns while preserving natural motion in the spine. Artificial disc arthroplasty is a good alternative for younger patients with single-level degenerated or herniated discs whereby we can avoid single-level fusion,
Matthew B. Kern, M.D., discusses minimally invasive surgery with a patient. says Dr. Kern. In fact, there is no need for fusion. There is also no need for a cervical collar, and patients have a quicker recovery. There is also a sparing of adjacent motion segments. For a cervical spine approach to disc arthroplasty in the operating room, a surgeon makes a small incision at the front of the neck and, isolating the diseased disc, extracts it from the spine. The adjacent vertebral bodies must be cleaned of any remaining tissue from the diseased disc and reformed slightly to accommodate the implant. When performing artificial disc arthroplasty in the cervical spine, Dr. Kern utilizes the ProDisc-C Total Disc Replacement, which gained approval from the Food and Drug Administration in December 2007. Comprised of two cobalt-chrome alloy endplates and a domed, ultra-high molecular weight polyethylene inlay, the device features a ball-and-socket design and mimics a healthy disc s ability to absorb the shock of motion while maintaining the necessary separation between Wide-Ranging Treatment Options Neurological Surgery, P.C., offers a full complement of spinal services, from conservative therapies to minimally invasive surgical interventions. Of the practice s 30 physicians, 12 surgeons including Matthew B. Kern, M.D., neurosurgeon at Neurological Surgery, P.C. specialize in treating spinal conditions and injuries. This breadth and depth of experience and expertise assures patients that the most suitable therapies can be applied to their individual presenting symptoms and conditions with the utmost efficacy. The wealth of treatment options include: + + artificial disc replacement + + cervical disc replacement + + cervical laminoplasty + + complete and minimally invasive spinal surgery + + facet joint injections + + image-guided spine surgery + + kyphoplasty + + lumbar epidural steroid and transforaminal epidural steroid injections + + lumbar spinous process plating + + lumbar sympathetic block + + microdiscectomy + + posterior lumbar interbody fusion + + sacroiliac joint steroid injection
Early on in spinal surgery, there was really only one approach, and that was accessing the spine from the back and performing everything through laminectomies. We now have many different options, given the patient s case, for the appropriate use of materials and approaches to the spine to address the two tenets of spinal surgery. The first is to decompress the neurological elements by taking pressure off the spinal cord or the nerve roots, and the second is stabilizing the spine. Matthew B. Kern, M.D., neurosurgeon at Neurological Surgery, P.C. METRx System tube in approximate location on the spine Evaluating spine films (MRI and plain films) individual vertebrae. Once implanted into the vacant space left by the extracted disc, the ProDisc-C Total Disc Replacement is affixed to the adjacent upper and lower vertebrae. The artificial disc arthroplasty procedure is applicable in the lumbar spine for low back pain, discogenic pain and degenerative disc disease. It carries the same advantages as when performed in the cervical spine, namely returning patients to their normal routines much more quickly than fusion surgery and protecting the spine from adjacentlevel disease. According to Dr. Kern, one of the challenges of both cervical and lumbar artificial disc arthroplasty emerges in the necessity to size the implant with precise accuracy and place the device in the exact proper location in the spine s midline. The recovery time for patients is typically dependent on the healing of their incisions, though Dr. Kern prepares his patients to begin increasing their levels of activity after 10 to 14 days. The Multilevel Solution In thinking about the cases in which multiple levels of the spine are affected by a spinal condition or injury which can often require spinal fusion via minimally invasive techniques Dr. Kern reflects on the beginnings of minimally invasive surgery. The mid-1990s saw the advent of the microendoscopic discectomy (MED), developed by neurosurgeon Kevin Foley. The procedure allowed physicians to access the spine and extract the diseased segments or place corrective devices through a tubular retractor. The instrument advanced surgical accuracy by attaching a camera and a light to the retractor, enhancing visibility during the procedure. When I first learned about the MED, I thought to myself, Wouldn t it be great if they developed this in such a way that I could use the microscope to look down the
Tools of the Trade Matthew B. Kern, M.D., examines a postoperative patient. tube instead of using the camera to look down the tube, says Dr. Kern. Less than a year later, I went to a meeting, and that is exactly what they did. With the shift to the microscope, a surgeon s visualization capability went from two-dimensional to three-dimensional. This, in turn, made it possible for surgeons to reduce the size of the already small, posterior incision. At Neurological Surgery, P.C., Dr. Kern utilizes the minimally invasive instrumentation under X-ray guidance to make a paraspinal incision and spread the muscle to access and remove the diseased bone rather than destroy the midline ligaments with a midline incision to remove the bone. He can then place a screw-and-rod structure or a bone graft to replace the extracted bony anatomy. The approach translates to less destabilization of the spine during surgery and a quicker healing process following surgery. In addition, minimally invasive spinal surgery affords patients decreased risk of infection and blood loss. In contrast to the typical three to six months of bracing required after traditional, open spinal surgery, patients who undergo minimally invasive spinal surgery can be stabilized in a back brace for approximately three weeks. In planning the details of the spinal fusion, Dr. Kern is also able to take advantage of the available options for instrumentation to improve the overall surgical outcomes. There are numerous companies that manufacture minimally invasive surgical systems, and I do not subscribe to only one company, he says. I tailor the operations to each patient and use the most appropriate system for the patient s anatomy and surgical goals. Finding the Right Fit While both the artificial disc arthroplasty and minimally invasive spinal fusion procedures represent significant developments in the discipline of spinal surgery, Dr. Kern weighs a patient s candidacy for each based on several aspects of his or her case beyond the number of levels of the spine impacted by the condition or injury in question. Radiculopathy also known as sciatica neurogenic claudication, severe stenosis, spinal instability and spondylolisthesis are markers indicating the appropriateness of spinal fusion, while a desire to perverse motion in the spine coupled with the presence of single-level disc disease would likely lead to artificial disc arthroplasty. Mechanical back pain worsened by walking, sitting or straightening the back and relieved when the patient is lying down would also indicate artificial disc arthroplasty. Proper patient selection only serves to enhance the efficacy of the surgical invention. As far as minimally invasive fusion surgery is concerned, because patients are As the landscape of spinal surgery has advanced and the tools with which surgeons achieve surgical goals have developed during the past 50 years, the permanent implants left to affect lasting improvements for patients have also transitioned through multiple generations of technology. As Matthew B. Kern, M.D., neurosurgeon at Neurological Surgery, P.C., explains, earlier spinal procedures relied on wire and rectangular implants made primarily of stainless steel. Today, the options for those fixtures including bolts, cages, hooks, plates, screws and wires have evolved from a single material to a plethora of biomaterial such as cobalt chrome, polyether ether ketone (PEEK) and titanium. Each substance has unique advantages for clinical application. In studies, cobalt chrome alloy wires have proven to result in higher yield and ultimate tensile loads compared to steel wires, and can be particularly effective in sublaminar implants for correcting spinal deformity. PEEK implants offer a radiolucent alternative in both orthopedic and trauma care, where metallic biomaterial may not be applicable. Additionally, unlike stainless steel which can create a blurred image when patients with these implants undergo a computed tomography or a magnetic resonance imaging scan titanium implants do not interfere with imaging technology. not having as much tissue destruction, they are getting out of the hospital much quicker and, when appropriately chosen, have an overall improved outcome, says Dr. Kern. In terms of artificial disc arthroplasty, once again, patients are able to get back to normal activity much quicker. I am seeing results that are equal to, if not better than, anterior fusion surgery. For more information about spinal services at Neurological Surgery, P.C., visit www.nspc.com. n Reprinted from Long Island md news