Case Study

Anterior Spine Surgery: a great way to help nerve pain

Written By: Stephen Byrne Neurosurgeon and Complex Spine Surgeon

Recently I had the pleasure of looking after a very fit and active 70 year old lady. She had previously enjoyed free climbing and hiking and had plans to trek Machu Pichu and to Everest Base Camp over the next 2 years! She presented to her GP with worsening pain radiating down the leg in the region of the L5 dermatome (lateral calf and dorsum of the foot) for 6 months. She struggled with getting around the local shopping centre and with some activities of daily living. Long walks became less and less frequent and she gave up many of the activities that she previously enjoyed. Rather than living with her pain, she presented to her GP who organised an MRI scan of her lumbar spine and a nerve injection. The injection helped her pain considerably but only for 3 days. She also tried physiotherapy and had some acupuncture but didn’t obtain lasting relief.

The patient was then referred to me for further management. She recounted the history above and explained her lifetime ambition to experience two of Earth’s wonders. Her neurological examination was significant only for some reduced sensation in the left L5 dermatome and some mild weakness of ankle dorsiflexion (4+/5). Her lumbar xrays showed a severe degenerative lumbar scoliosis and almost complete loss of disc height at L5/S1. Consequently, her MRI scan showed significant compression of her L5 nerve root which appeared to be compressed by the superior aspect of the S1 vertebral body against the L5 pedicle. I discussed her management options with her in detail. These options included soldiering on with pain, taking painkillers, physiotherapy or alternative therapy, more injections or surgery. Ultimately, the patient chose to have an operation and I suggested an L5/S1 anterior lumbar interbody fusion. The aim of the proposed surgery would be to help her presenting complaint only. We agreed that a more limited procedure would be best as she’d be unlikely to return to her previous levels of activity if she underwent a multilevel deformity correction procedure.

Her operation was uncomplicated. Working below the aortic bifurcation and common iliac vessels the L5/S1 disc was removed and replaced with an interbody fusion device in order to ‘jack open’ the space around the L5 nerve root. The operation began at 1130 and she was in recovery by 1300. She was walking that afternoon and was discharged home after one night in hospital. Her pain had resolved and she was off all painkillers after 6 days. She continues to do well on follow up and I have cleared her to trek to Mount Everest and Machu Picchu. She has already returned to hiking and free climbing.

Spine surgery pearls

  • Anterior spine surgery is associated with a rapid recovery as it doesn’t involve cutting muscle. It is ideal at L5/S1 as the working space is below the major blood vessels
  • The surgeon can discuss the natural history of the condition as well as the role of non-operative and operative treatment and their relative efficacy
  • A range of open or minimally invasive treatment strategies are now available and can be tailored to individual patient’s needs

MRI image showing L5 nerve root compression.

Xray showing degenerative scoliosis and obliteration of L5/S1 disc space.

Post operative xrays showing L5/S1 interbody device and restoration of the foraminal height at L5/S1.   

Written By: Stephen Byrne Neurosurgeon and Complex Spine Surgeon

Spinal Deformity – a Multidisciplinary Solution

A man in his 60’s consulted me with intractable back pains associated with degeneration of his lumbar spine.  There was widespread degeneration of the lumbar facets and discs, and he presented with a significant history of narcotic use, in a vane attempt to get his pains better controlled.

Consultation at that stage and discussions regarding options for management ultimately lead to attempt at surgical correction of his pains, having failed other conservative treatment options over the years leading up to his surgical review.  A long construct fusion was undertaken with screws from T9 down to the pelvis and whilst there were initial improvements in the discomforts, the patient represented with worsening pains down low in his back roughly 12 months later.  Scans at the time revealed that the construct had failed, with the rod disengaged from the screws at the sacral level and loosening of the screws at L5.  The stress and forces applied to the spine during the attempted spinal reconstruction were excessive and failure ensued.  The lower screws were removed.

Despite improvement in his local symptoms (pains down low in his lumbar spine), he developed progressive deformity and spinal imbalance, with widespread pain and disability.  His L4/5 and L5S1 segments became kyphotic throwing his balances forward significantly.  He was back on his narcotic medication (kapanol 100mg bd) and was only able to ambulate with the assistance of a 4 wheel walker.

Standing x-rays at the time revealed the extent of his spinal deformity.  His imbalance was pronounced with his head well forward of the expected balance point over the pelvis. 

Consultation was sought from Dr Steven Yang, colleague, and expert in spinal deformity correction.  After careful consultation and consideration of the case, a combined surgical case was undertaken with Dr Yang to address the imbalance issues.

In a 10 hour procedure involving neurosurgery and orthopaedic surgery, pedicle ubtraction osteotomies were undertaken to allow for restoration of the sagittal balances – ultimately allowing the patient to be able to stand upright once again.

His pain improved considerably and his narcotic use has decreased.  He was off all Kapanol and using endone sparingly.  He was far from perfect, but was considerably better, and he considered that his major reconstruction was well worth while.

A combined approach with neurosurgeons and expert orthopaedic spinal surgeons saw a great outcome in this case.  Selected patients with spinal deformity will do very well from spinal reconstruction surgeries.  Risks of this type of surgery are considerable, but in carefully selected cases with extensive counselling, lives can be turned around.

 Dr Michael Bryant, Neurosurgeon and Spinal Surgeon 

Neck pains and occipital headaches – a rare pathology

A 69 year old male presented to his GP with a slowly progressive, 6 month history of left sided neck pains and occipital headaches. Examination was unremarkable and in particular, strengths and reflexes in all 4 limbs were normal.

CT scan revealed some degenerative changes low down in the cervical facet joints and a referral was made to an orthopaedic spinal specialist, and from here facet joint injections were undertaken.

When this procedure provided no relief, a greater occipital nerve injection was arranged under CT guidance and was on this procedure that the causative pathology was finally identified.

When the MRI scan was finally undertaken, a contrast enhancing, durally based, ventral and left sided tumour was identified behind C1 and C2.

Axial, Coronal and Sagittal MRI with gadolinium shoeing the tumour displacing and compressing the cervical cord.

With the benefit of hindsight, it was obviously the tumour causing the neck pain and occipital neuralgia.

The appearances were typical for a spinal menigioma and options were considered.

Analgesics alone were trialled initially, and whilst some improvements were seen with dexamethasone, lyrica and targin, the side effect profile was considerable, and the analgesia was incomplete.  Consideration was given to radiation therapy up front and surgery was offered. In most clinical circumstances surgery would be considered treatment of choice for mengioma, and it was indeed the way the patient elected to go.

Informed consent was undertaken for C1 and C2 laminectomy with resection of the tumour. Spinal cord monitoring of motor and sensory potentials was undertaken to ensure real time feedback of potential spinal cord injury. The tumour was able to be resected in a 4 hour procedure, with 2 surgeons (thanks to Dr Hamish Alexander) collaborating to increase safety and avoid fatigue related mistakes. Motor and Sensory potentials were unchanged throughout the procedure and the patient woke without neurological deficit. He was able to be discharged 5 days after his procedure, once the discomfort of the neck wound settled.

The spinal cord is seen superiorly and C2 and C3 nerve rootlets are seen to cross over the top of the tumour to the edge of the dural opening.

Roughly 98% of the tumour was resected.  A tiny piece of tumour was left where the C2 nerve root pierced the lateral dura. The dural attachment of the tumour ventrally was cauterised, but unable to be resected. Unfortunately, the meningioma histology was confirmed as ‘atypical’, which significantly increases the chances of tumour recurrence. For this reason, the patient has been referred on by our Neuro-Oncology Nurse Practitioner for consideration of post-operative radiation therapy.

Whilst it is acknowledged that common things occur commonly, a careful history, recognising occipital referral of pains (C2 and C3 irritation), may have prevented an unnecessary intervention into the lower cervical facets.

-By Dr Michael Bryant, Neurosurgeon and Spinal Surgeon 

First O’arm spinal surgery on the Sunshine Coast

Recently, I had the pleasure of undertaking the first ever ‘O arm’ spinal surgery case at the Buderim Private Hospital. The ‘O arm’ is a sophisticated device that provides surgeon with real-time CT quality imaging intraoperatively during spinal fusion procedures.

Spinal fusion surgery is technically demanding and stressful for both patients and surgeons, it’s vital to have access to the most sophisticated technology in order to reduce the rate of complications.

I have been following a 71 year old man for some time due to his spinal problems. He initially had a spinal operation carried out in the 1980’s and had been well for sometime until the degenerative changes in his spine began to cause a lumbar radiculopathy due to compression of the L3 nerve root. He had impaired sensation in the L3 dermatome (anterior thigh), weakness in the L3 myotome (knee extension), quadriceps muscle wasting and an absent knee jerk reflex. He had symptoms for sometime and had exhausted non-surgical treatment.

Non surgical treatment includes, doing nothing or taking painkillers, as the natural history is favourable; injections, physiotherapy and pain management specialist involvement. His quality of life was poor and he had given up hobbies that he had previously enjoyed. The L3 nerve root was compressed in the neural foramen and this is best addressed by inserting an interbody device to increase the neural foraminal height and decompress the nerve as well as stabilising the L3/4 motion segment with pedicle screws. Both the patient and myself were keen to reduce the operative time, blood loss and hospital stay but this had historically been quite difficult after major fusion procedures. The ‘O arm’ allowed me to decompress the spinal nerves, insert an inter body cage and fuse L3/4 through two 3.5cm incisions. Blood loss was 300ml and he was discharged home on the 2nd post operative day. He had complete resolution of his radicular symptoms.

          

I’m very excited about using the ‘O arm’ on the Sunshine Coast as we now have access to technology that was only previously available in Brisbane.

The last 12 months have been very exciting for Sunshine Coast Brain and Spine as we have now welcomed another surgeon to our practice Dr Hazem Akil. I have also been able to carry out the first ever craniotomy procedures in order to remove brain tumours in the Sunshine Coast and more patients are benefiting from local treatment. Cranial surgery will soon be introduced at the Buderim Private Hospital and the vast majority of neurosurgery and complex spine surgery patients can now be managed at SCUPH and the Buderim Private Hospital.

By – Dr Stephen Byrne MBChB, MRCSEd, FRACS

Neurosurgeon & Spinal Surgeon

Ependymomas

A 75 year old female presented to her local hospital with pains in the chest and was admitted under a Respiratory Physician with (incidental) rib fractures, that in retrospect were old.  Clinical suspicion lead to further investigation and the diagnosis of an intradural mass at the level of T6 and T7 vertebrae.

An MRI suggested showed the mass with significant spinal cord compression, but despite these rather dramatic findings on scan, the patient maintained good strength in her lower limbs and normal sensation and function of the bladder and bowel.

Commenced on dexamethasone, she was taken to theatre after transfer to St Andrew’s Hospital 3 days after her diagnosis was made.

Intraoperative findings were that of a mass arising from within the substance of the spinal cord.  Resection required careful dissection out of the cord itself.

Post-operatively function has returned quite quickly to normal.  The only deficit was some loss of joint position sense (proprioception) – as one may expect from this area of the spinal cord itself (the dorsal columns).

2 weeks after her operation she is off to rehab to regain her confidence, but currently she is walking without any assistance and has normal bladder and bowel function.

Histology revealed Anaplastic Ependymoma (WHO Grade III).  The rest of the brain and spine were clear of any obvious tumour.

A Brief Discussion 

Ependymomas are rare tumours and make up about 3% of the primary tumours that we as neurosurgeons encounter.  The more aggressive anaplastic tumour is even rarer and possibly accounts for 5-10% of ependymal tumours.

Because the numbers of this particular tumour as so low, the exact history of the disease is not entirely clear.  Almost all anaplastic ependymomas will recur and current treatment recommendations are for excision followed by radiation therapy and possible chemotherapy.

Whilst quite a “pretty” tumour histologically, their more aggressive behaviour can see them behave in a “not-so-pretty” clinical way.

This patient will be followed closely post radiation for any signs of recurrence.

– Dr Michael Bryant, Neurosurgeon and Spinal Surgeon 

Going off legs: thoracic myelopathy

Most unstable spinal fractures affect the thoracolumbar junction or the cervical spine. Fractures elsewhere in the spinal column tend to be stabilised by the rib cage and rarely cause neurological deficits. Whenever a fracture causes spinal cord compression elsewhere in the thoracic spine, a secondary process such as infection (osteomyelitis) or neoplasm (primary or secondary) is more likely to be present. With advancing age, the transitional cervico-thoracic region is subject to degenerative and osteoporotic changes and spinal cord compression can occur.

In a recent case of an 86 year old man with a history of progressive gait disturbance and recurrent falls, who had previously lived independently along with his wife, they were both ‘high functioning’ and in good health. Recently, he had began to use a 4 wheel walker to get around his home and had stopped going out. He had a pacemaker and was a Jehovah’s Witness. Neurologically, it was noted that he had a left lower limb monoparesis 2/5 proximally and 4+/5 distally and a T4 sensory level. He had an ASIA D incomplete spinal cord injury on the ASIA impairment scale. His CT and MRI scan demonstrated a thoracic compression fracture and translation of one thoracic vertebra over the other along with some degenerative changes causing a severe spinal stenosis at T2/3 and cord oedema. The natural history of this condition in an elderly patient is inevitable loss of independence, eventual paraplegia and a high risk of death due to complications of immobility.

Pre operative T2 sagittal MRI showing translation of T2 over T2 and cord compression with cord oedema

Due to the progressive and emergent nature of the patients presentation and after a frank discussion of the risks and benefits of surgery versus non-operative care, surgical decompression of the spinal cord and stabilisation of the fracture was recommended. The patient underwent a T2/3 decompression and T1-3 pedicle screw fixation and was managed in Intensive Care for 24 hours post operatively. After a further three weeks of inpatient rehabilitation, the patient was discharged home. The patients walking had improved significantly and the strength in their legs had almost normalised at the final review. Due to ongoing problems with proprioception however, the patient was still using a 4 wheel walker but with the aim that he can dispense with this in time – an excellent result.

Post operative xrays showing pedicle screw fixation from T1-T3

Thoracic disc pearls

  • Patients with complete or incomplete cord injuries due to fracture usually require surgery.
  • Patients with thoracic fractures (other than thoraco-lumbar junction) and neurological deficits should be actively investigated for secondary processes such as cancer, infection and osteoporosis using CT, MRI and bone scans.
  • Whether to proceed with surgery requires a full and frank discussion with the patient and their family about the natural history or their condition and what surgery can be reasonably expected to achieve.

– By Dr Stephen Byrne

Thoracic Disc Herniation

Most of the degenerative spinal pathology that we see as specialists as well as in primary care affects the lumbar or cervical spine. This is interesting as the thoracic spine contains a similar number of intervertebral discs and facet joints than the rest of the spine put together. However, the relative immobility of the thoracic region due to the rib cage limits motion-dependent degenerative processes such that most spinal surgeons would really only operate on thoracic disc herniations once or twice over a several year period.

Recently I saw a 52 year old lady with a history of progressive gait disturbance, falls and chest wall pain. She had also recently begun to mobilise with a stick. Neurologically, I noted that she had a Brown-Sequard syndrome (with motor weakness and loss of proprioception and vibrations sense affecting one leg and loss of pain and temperature sensation affecting her contralateral leg). Her CT and MRI scan demonstrated a central and paracentral thoracic disc bulge compressing the spinal cord and a thoracic nerve root.

Figure 1                                                                  Figure 2

Figures 1 and 2 Sagittal and axial T2 MRI images demonstrating a paracentral T10/11 disc prolapse compressing the spinal cord

Due to the progressive and emergent nature of her presentation and after a frank discussion of the risks and benefits of surgery versus non-operative care, I recommended surgical decompression of the spinal cord. My preferred approach for decompressing the spinal cord due to a disc herniation is via a thoracotomy as this means that absolutely no retraction is placed on the spinal cord as the surgeon can directly work on anteriorly located pathology rather than passing instruments from behind to in front of the spinal cord. The patient subsequently underwent a left sided thoracotomy, removal of the head of the 11th rib and partial T10/11 vertebrectomy and discectomy. She spent a couple of days in HDU as pain control was challenging for her before being discharged home. At recent follow-up, both her chest wall pain and walking difficulties have significantly improved.


Figure 3                                                               Figure 4

Figures 3 and 4 – Coronal and sagittal CT images showing the extent of bony resection at T10/11 to perform a thoracic discectomy via a thoracotomy


Thoracic disc pearls

  • Many patients (up to around a third) have asymptomatic disc protrusions that, while impressive on imaging, do not require surgery.
  • Usually occur below T8 as the thoracic spine becomes ‘transitional’ and the degree of segmental motion increases.
  • Most thoracic disc prolapses are calcified making surgery more difficult.
  • Different approaches are possible to remove thoracic discs for cord compression but a thoracotomy is associated with the lowest risk of neurological injury.


– By Dr Stephen Byrne

Sit and suffer

blog-walk-to-work-week-1024x859 I am very often asked by patients, both those who have undergone surgery and those for whom surgery for lumbar back ache is not available, what exercise regime they should follow. There is a generally held view that a structured exercise program must be good for maintaining spinal hygiene and there is no end of work hardening programmes, core strength exercise programmes and abdominal muscle strengthening regimes etc. etc. touted to restore the spine to pristine health, almost all of them lacking much hard evidence of real efficacy.

I tell them to walk. Preferably 30km a day. This is usually accompanied by stunned silence in response, followed by: “How can I possibly do that?” I point out to them that the human body was adapted by evolution to track 30km across the African Savannah every morning to catch a Mastodon for lunch and it has not evolved much beyond that. I know that Mastadons are creatures of the Serbian Tundra and not the African plains but I am using poetic license to paint a picture.

Some years ago I met a patient who came to see me about issues unrelated to his back but he started talking about his back problems: he injured himself and developed severe back ache. He sought treatment from a variety of physiotherapists and chiropractors and manipulators over a period of many months all to no avail; eventually he was referred to a surgeon who then carried out some form of operative procedure on his lumbar spine but even after that he was not much better. He was under the New Zealand ACC system (this occurred when I was working in New Zealand) and following the failed surgery he went on a further program of physiotherapy, hydrotherapy, pain management and spent some 3-4 years undergoing a variety of increasingly futile attempts to rid him of his disability.

He said that finally one day he got sick of being an invalid and decided he was going to go out and get himself a job, back pain or no back pain. The only job that he could find was to sell Sky subscriptions as a door to door salesman (Sky is the New Zealand version of Fox) and so he trudged door to door in the wind, rain and snow (this was in Christchurch) burning up many kilometres of footpath a day. “You know Dr B, after 3 months my back pain had completely gone and I haven’t had a day of back pain since.” Naturally this is an anecdote but there is support in the literature for both a vertical (as opposed to sitting) lifestyle and walking as a low impact programme for spinal health.

So walking is very much the best exercise for maintaining spinal hygiene. Swimming is just about as good and bike riding (as long as this doesn’t involve hurling yourself off a mountain bike) is not bad either.

– Dr Janusz Bonkowski

Just don’t do it!

Falls off ladders are a surprisingly common injury in our community, and whilst most amount to nothing more than dented pride when they occur, some are considerably more serious – just ask Mr Ian (Molly) Meldrum.

Recently we had cause to treat yet another considerably more serious “ladder injury”.  A 56 year old man had been painting his ceilings at home when he fell off his ladder.  Whilst this may read as any other 6 foot step ladder incident, this particular event was made all that more serious by the fact that the ladder was perched precariously on the kitchen bench at the time.

The patient had actually managed to paint a considerable portion of the ceiling, but in attempting to stretch for that extra few centimeters, over balanced the ladder which proceeded to topple out from underneath him.

He struck his head on the stone bench top on the way down and sustained a hyperextension injury to his neck. 

His presenting neurology was of elbow extension weakness of the right arm in the setting of severe neck and arm pain.  Pre-operative MRI (see image above) showed evidence of disc disruption at the C5/6 and C6/7 levels with considerable nerve root compromise at each of these levels.

At operation the C6/7 was grossly disrupted and gaped open whilst the C5/6 was less affected.  A two level discectomy and fusion was undertaken (see right image) and fortunately the patient was able to be discharged without any persisting neurology 4 days later.

The moral of the story is obvious…

–  Dr Michael Bryant