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
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
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
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