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Spine surgery done the “classic” way is traditionally done with an open approach, meaning that the surgical area being operated on is opened with a long incision to allow full view and access to the anatomy by the surgeon. In the past recent years, there have been advances in technology that have allowed spinal conditions to be treated with the minimally invasive spinal surgery (MISS) approach.Dr. Brusovanik Helps CBS4's Eliott Rodriguez Without Surgery 2
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Pain After Surgery Assessment

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Why Do I Still Have Pain After Back Or Neck Surgery?
I’m sorry that you are still suffering. The reality for patients like you who have had back surgery or neck surgery and who are still having pain is that the reasons for that pain, it’s a very short list, there are very few such reasons. Nonunion or pseudarthrosis is one, and adjacent level disease is the other. Let’s talk about each one in detail.

 

What Is Adjacent Level Disease?
If you’ve had a spinal fusion, a neck fusion, or a back fusion, that operation essentially should have corrected the previous deformity or instability and immobilized a segment of your spine. Unfortunately, especially with classic spine surgery, immobilizing a segment of your spine resulted in a high number of patients having another problem either above or below that fused segment, and that’s called adjacent level disease.

 

How To Correct Adjacent Level Disease
If you have an adjacent level problem either above or below your neck fusion or your back fusion, some of the newer methods of fixing that include disc placement both above or below your old fusion in the neck, correction of fusions through a minimal invasive lateral or anterior exposure. This way of getting to the spine minimizes the morbidity, with little blood loss and no injury to muscle. These patients get back to their normal life a lot faster. Most do not need physical therapy after these minimal invasive revisions.

 

What Is A Spinal Nonunion?
What is a spinal non-union? You only hear about a spinal non-union when you’ve had one. Essentially, the patients who have already had spine surgery, a fusion surgery was attempted where you take out the disc and you attempt to make the vertebral bones knit together, hopefully in a better position. When that operation fails, these patients are in excruciating pain. A lot of them blame themselves, a lot of them think that they didn’t do enough therapy or that they did something wrong. Almost always it’s not the patient’s fault. Almost always it’s an issue within the operation and these patients are all fixable. Spinal non-union is also known by names like Pseudarthrosis or failure of fusion. Unfortunately, it’s also known as a failed back surgery syndrome. Very, very painful.

 

How Can A Spinal NonUnion Be Treated?
What can be done for a spinal non-union? Nowadays, with the advent of minimally-invasive surgery, specifically, anterior surgery, where spine surgeons access the front of the spine, that’s the pathway to correct a spinal non-union. Frequently, a non-union is a the result of an operation called a TLIF or a PLIF where a little cage was implanted through the back, around the spinal canal, and into the disc. When that becomes loose, when the screws are loose, going to the scar tissue is very dangerous. Therefore, going to the front of the spine lets you remove the old instrumentation through the front in a much safer way, but more importantly, it lets you re-fuse the spine in a much better position, in a taller position which can only be achieved by going to the front of the spine. Don’t despair, if you have a spinal non-union, it’s fixable.

 

Why New Surgery Techniques Are Successful With Adjacent Level Disease
Adjacent level disease is easier to understand in terms of a tree. Imagine a tree was leaning slowly and surely, but faster and faster with time, because the more it leans, the heavier weight those roots have to carry. A classic spine surgery would take that leaning human spine and it would immobilize a segment and reliably the rest of the spine would just turn right above. Now the classic spine surgeon did not address what’s called sagittal balance for this leaning problem that we all have with time. Now, new spine surgery allows surgeons like me to get to the front of the spine, where we can restore the height of the anterior column or the front part of the spine, thereby getting that tree to be upright. And once the tree’s upright, the chances that he will keep leaning in the chair and another level will go back goes down to 3%.

 

Do I need an MRI & CAT SCAN?/span>
If you have a back operation or a neck operation, specifically a fusion and you are still suffering, in order to figure out exactly why you are suffering, is it an adjacent level problem, or is it a nonunion or pseudarthrosis? We will need to obtain two studies, an MRI and a CAT scan. The MRI will show us soft tissues above and below your fusion. MRI is for the adjacent level disease problem. A CAT scan will show us within the fusion and especially since the metal will frequently alter the images or an MRI, that CAT scan is essential to actually look inside the fusion and make certain where there is a failure to knit together a nonunion also known as a pseudarthrosis.

 

Adjacent Level Disease After A Fusion
With an adjacent level problem after a fusion, the solutions are actually very objective. This new technology that you’ll see a lot of younger surgeons are taking advantage of, this new technology actually allows surgeons to sneak in, correct the adjacent problem and sneak out. So whether it’s an adjacent problem in the neck or an adjacent problem in the lower back, you can still expect a minimal invasive option with quick recovery and return to a pain free life.

 

Patients Who Take Narcotics After Spine Surgery
If you’ve already had a spinal operation, a fusion in your back and neck, and you are still suffering, but someone has given you narcotics, and if you’ve been taking these narcotics for a long period of time, then you are probably suffering from some of the common things that are associated with usage of narcotics. Specifically withdrawal if you stop, tolerance, meaning that you have to take more and more and more, and dependency. That means that you feel like if you don’t take more, you feel bad. The patients who have an objective spinal problem should never be treated with narcotics, but the reality is that a lot of them are. For these patients, we go through a short period of aggressive diminution of narcotic usage. I give patients back their narcotics once I correct the problem. And once the problem is corrected and their original problem is gone, they can then take their time over about a month and stop the narcotics.

 

PATIENT TESTIMONIAL

I’m a 77 year old retired physician. For 1 year I had severe sciatic pain radiating from my right lower back to my right lower leg. I couldn’t walk more than 50 feet before the pain became severe. Dr. Georgiy Brusovanik performed surgery at Doctors hospital in Coral Gables replacing all the disk in my lumbar spine because the degeneration was severe.Procedure was done in two stages.The surgery was very successful.My recovery each time was shorter than i expected.I am now able to walk my dogs up to 12 city blocks per day.I am very pleased with the care i received and feel that Dr. Brusovanik expertise and kind manor helped me to achieve the success i had.

Dr. Burton Silver, MD
Dermatologic Surgeon
View Original Card

 

Spinal Non-Union

Spinal non-union is a common cause of failed back surgery syndrome. Specifically, it’s the fusion surgery that is the culprit in this diagnosis. There’s a long history of improvement in the technology of fusion. Many patients had the old style of fusion that had an extremely high rate of failure. A common mode of failure is non-union or Pseudoarthrosis. This results in severe pain and dysfunction in patients about 6 months to a year after their original fusion surgery. These patients have a characteristic set of symptoms that is common. This diagnosis is associated with severe dysfunction and frequent failure of conservative care such as injections and physical therapy. There’s a strong emotional component to failed back surgery, as many patients and, unfortunately, many doctors tend to blame the patients. It is often extremely rewarding to heal the patient’s back pain, as well as their emotional state with corrective minimally invasive spinal surgery for pseudoarthrosis or nonunion.

Background | Pseudoarthrosis is failure to unite. When fusion surgery is undertaken, the goal of the operation is to restructure a deformed spine and hold it in place. That is the definition of fusion surgery. Fusion is usually accomplished with screws. Historically, fusions were done without screws. Placement of screws makes a big difference and the type of exposure makes a big difference. It also matters whether it was an ALIF, a TLIF, or a PLIF, if disc work was done. Once fusion surgery is undertaken, the patient is in a “race”. The race is between the ability of the spinal bones to mend together versus time for loosening of hardware. Imagine placing hardware into a living tree. Imagine placing a screw into a branch. With time, that screw may loosen.

The Symptoms | These patients are in a lot of pain and there are a lot of reasons for that. When screw loosens, they’re literally creating micro fractures and that hurts as any other fracture would. Second, if a cage backs up due to micro motion, it may start compressing a nerve, and that would cause pain going down the buttocks or the legs. The instability at the same level will produce micro motion that produces a significant background noise of constant pain. Patients will report that they’re never free from pain, and they frequently have to tense their core to an extreme extent doing any kind of transitional movements such as standing up from siting or changing from a laying position to siting down. These patients will also complain of severe pain that spikes and makes them unable to function due to back spasms. These spasms may actually occur due to nerve compression as the body tries to immobilize the painful segment. Whether it’s nerve irritation or actual instability, your muscles are trying to protect your bones from shearing and moving in a way that is traumatic.

Adjacent Level Disease

Adjacent level disease is a common cause of pain after back and neck surgery. Fusion surgery is also the culprit. Immobilizing a segment of the spine results in translation of forces above and below the fuse segment. Many studies have shown high rate of adjacent level disease especially when a fusion is adjacent to a disc with some degeneration. Patient will complain of new or different pain than what they had before their original operation. In order to diagnose this problem an MRI is indicated. With an MRI both the doctor and the patient could clearly see if a disc above or below the fusion has degenerated. To confirm whether that disk degeneration is indeed associated with the patient’s new pain, and injection may be indicated. When we confirm the source of patient’s pain we could use the new minimally invasive techniques to address the adjacent disc problem. Frequently this means disc replacement, but sometimes if the degeneration is far gone and adjacent minimally invasive fusion may be indicated as well. It’s really rewarding to help patients with adjacent level disease get back to their normal lives.

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