Spine surgery has traditionally been done as an open surgery. However, in recent years, there have been technological advances have allowed more back and neck conditions to be treated with minimally invasive surgical techniques.
The orthopaedic surgeons at MedStar Orthopaedic Institute have extensive training in the most advanced and innovative surgical procedures to treat back pain, including minimally invasive back surgery and motion sparing surgery.
In this segment, Dr. Oliver Tannous discusses the latest advances in spine surgery at Medstar Washington Hospital Center.
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The Latest Advances in Spine Surgery
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Learn more about Oliver O. Tannous, MD
Oliver O. Tannous, MD
Oliver Tannous, MD, is an orthopaedic spine surgeon at MedStar Washington Hospital Center. As a spine specialist, he utilizes state-of-the-art, minimally invasive and motion preservation techniques to treat conditions of the bones, discs, and nerves of the neck and back.Learn more about Oliver O. Tannous, MD
Transcription:
The Latest Advances in Spine Surgery
Melanie Cole (Host): Spine surgery has traditionally been done as open surgery, but in recent years, however, technological advances have allowed more back and neck conditions to be treated with minimally invasive surgical techniques. My guest today is Dr. Oliver Tannous. He’s an Orthopedic Spine Surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Tannous. What are some of the most common causes of back pain, and when you see a patient, when does it then become surgical?
Dr. Oliver Tannous (Guest): Hi Melanie, thanks for having me back. It’s good to be here. Great question. Back pain is, I think, the second most common reason to go to a medical office or Emergency Room after respiratory causes. It’s something that we see very commonly – not just me as a spine surgeon, but I think any primary care physician sees, as well. The vast majority of back pain, thankfully, is not at all serious. It tends to be muscle strains or some inflammation that happens around the spine from just good old-fashioned arthritis. It’s very rare that back pain then becomes a surgical problem.
Unfortunately, in 2017, as spine surgeons, we are terrible, and we have abysmal results, for the most part, when we try to treat back pain, and back pain only with surgery. What I explain to all of my patients is that when they have arthritis that causes back pain, but where the bone spurs have also grown and now are pinching on the nerves and causing nerve pain to travel down the legs -- as spine surgeons, we are very good at treating nerve pain that’s secondary to arthritis in the back.
When I have my patients come to see me, I really try figure out how much of their pain is really in their back, and how much of their pain is the nerve symptoms – the neurologic symptoms that are traveling down their legs. If it’s predominantly leg pain, well, I tell them I have a really good surgery to treat that, but if it’s predominantly back pain, I tell them that I probably am not going to make their back pain better, and then at that point, we really try to focus on non-surgical treatments and try to give them some pain relief.
Melanie: When we talk about – people hear the words minimally-invasive – and what does that mean, and what are some of the benefits of a minimally invasive procedure versus the traditional, more invasive procedures that you might have done in the past?
Dr. Tannous: Very good question. Everybody comes into the clinic, and everybody wants to know what this whole minimally invasive spine surgery is all about. Everyone wants the three-millimeter incision, and they want to avoid the bigger procedures. A lot has advanced in spine surgery over the past ten or fifteen years, but really over the past five years, as well. For some people – and I stress that – for some people, they are great candidates for a minimally invasive procedure. All that means is that we disrupt less muscle; we disrupt and take out less bone to accomplish the same goals.
The goals of spine surgery, first and foremost, when people have a neurologic deficit, you have to decompress the nerve. If you don’t decompress the nerve, you don’t alleviate the neurologic symptoms, and people don’t get relief of their leg pain or their quote-unquote – what people call sciatica.
Number two, if there’s any instability, you have to stabilize the spine. Traditionally, to do a spinal fusion to stabilize the spine, it used to be a big, open incision down the back and you spread all the muscles open to get down to the spine and do the work that you have to do. For some people, when the disease is so advanced, this is still the golden standard. This is still the way it needs to be done. There’s a significant subset of patients where we can accomplish the same goals, but instead of making a four or five-inch incision, we can potentially use a one-inch incision. But then again, it’s not really the size of the incision that matters; it’s how much muscle has been dissected off of the spine, and how much of the structures surrounding the spine have been disrupted in order to do the surgery. That’s really what the concept of minimally invasive spine surgery is. It’s not necessarily the size of the incision, but it’s how much of the dissection has taken place in order to accomplish that goal.
A really nice technology that has developed over the past ten years is doing spine fusions from the size as opposed to from the back. Coming from the side, there’s really very minimal muscle, you’re moving the bowel contents out of the way, and you pretty much have direct access to the spine without having to take down any muscle insertions. Versus having to do it from the back, you have to take down all of the big, robust, thick, paraspinal muscles that need to be dissected out of the way in order to access the spine.
And the same goes for decompressions. Traditionally, to do a decompression, you would go from the back and make a much bigger incision and then dissect all of the muscles out of the way. Today, we can do a lot of our decompressions through little tubes. The nice thing about these tubes is that instead of dissecting the muscles out of the way, you’re spreading them out of the way. You’re not damaging muscle fibers. You’re not ending up with high amounts of blood loss, so our techniques have become a lot more refined and a lot more targeted depending on which nerve is being pinched and where the pathology is in the spine – where the arthritis is in the spine.
Melanie: Dr. Tannous, you mentioned the word fusion, and right away, patients think, “Okay, now I’m not going to have any range of motion in my spine,” whether we’re talking about the neck, or cervical disk replacement, or in spine surgery. Are these motion preservation techniques? What can you tell them about what they can expect afterward?
Dr. Tannous: Excellent question. That’s another one of the major advances in spine surgery over the past ten years or so. Especially in the next -- not so much in the lumbar spine, yet. I don’t think we’re quite there yet with the technology -- but especially in the neck, the advent of cervical disk replacements has really changed, I think, the playing field for a lot of patients.
Traditionally, if patients came in and they had pinching of the nerves in the neck, the gold standard for relieving that pinched nerve and stabilizing the cervical spine – which is the neck – was to do what we called an anterior cervical diskectomy and fusion or an ACDF. What this is, is you go through the front of the neck, you move all of the vital structures out of the way, you take the disk out, you decompress the nerves in the spinal cord. You put a piece of bone in that spot, and then you stabilize it with screws and plates, and what happens over time is that bone will then grow into the bones in the spine.
For the most part, it still is the gold standard in 2017, but what’s nice now is that we have the option to do cervical disk replacements. For the right patient – and I won’t go into the details of who that right patient is – but in general, it tends to be younger patients who don’t have a lot of deformities, who don’t have a lot of arthritis, who have a pinched nerve. You can do the same thing. You can go to the front of the spine; you take the disk, you decompress the nerves. But now, instead of putting a piece of bone in there, you’re putting a mobile implant in there that essentially reproduces the natural motion of the neck.
The nice thing about that is that the one thing we know about spine surgery is that it isn’t just one joint. For example, in the neck, you have seven joints, right? There are seven levels. When people come in in their 30s, 40s, and 50s, to have one level addressed, there’s about a 3% chance per year that they’ll have to have another level addressed down the road. We think that cervical disk replacements are preserving the natural motion of the spine, transferring less stress to the other levels above or below, and potentially minimizing the risk of having to have another surgery down the road above or below the level where the disk replacement took place. It’s a very promising technology. It’s been FDA approved now for both One and Two-level disk replacements. In my experience, I’ve had patients have tremendous results.
Melanie: What do you see the future of spine surgery? What’s coming down the path?
Dr. Tannous: That’s a really good question. I think the future of spine surgery, as for medicine in general, is going to be an evolution and emerging of medicine and technology, especially with the technology. Robotics are advancing; navigation is advancing. Our ability to accomplish the same goals of surgery with smaller incisions, less invasive techniques, I think over the course of the next five or ten years, we’re really going to see technology and technique merge together.
At the end of the day, technology will never replace a good clinician. It will never replace someone sitting down and listening to the patient, and really understanding the story and coming up with the right diagnosis. It will never replace technical ability, but it will allow surgeons who have all of these abilities to really take it to the next level and minimize the treatment side effects and optimize patient outcomes. I think we’re at a very exciting time in the evolution of medicine, and I think we have a lot to look forward to in the next five or ten years. Especially in spine surgery where we’re just at the beginning of motion preservation techniques, and of minimally invasive techniques.
Melanie: Thank you, so much. It’s really great information, Dr. Tannous. Thank you for being with us, today. This is Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole, thanks so much, for listening.
The Latest Advances in Spine Surgery
Melanie Cole (Host): Spine surgery has traditionally been done as open surgery, but in recent years, however, technological advances have allowed more back and neck conditions to be treated with minimally invasive surgical techniques. My guest today is Dr. Oliver Tannous. He’s an Orthopedic Spine Surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Tannous. What are some of the most common causes of back pain, and when you see a patient, when does it then become surgical?
Dr. Oliver Tannous (Guest): Hi Melanie, thanks for having me back. It’s good to be here. Great question. Back pain is, I think, the second most common reason to go to a medical office or Emergency Room after respiratory causes. It’s something that we see very commonly – not just me as a spine surgeon, but I think any primary care physician sees, as well. The vast majority of back pain, thankfully, is not at all serious. It tends to be muscle strains or some inflammation that happens around the spine from just good old-fashioned arthritis. It’s very rare that back pain then becomes a surgical problem.
Unfortunately, in 2017, as spine surgeons, we are terrible, and we have abysmal results, for the most part, when we try to treat back pain, and back pain only with surgery. What I explain to all of my patients is that when they have arthritis that causes back pain, but where the bone spurs have also grown and now are pinching on the nerves and causing nerve pain to travel down the legs -- as spine surgeons, we are very good at treating nerve pain that’s secondary to arthritis in the back.
When I have my patients come to see me, I really try figure out how much of their pain is really in their back, and how much of their pain is the nerve symptoms – the neurologic symptoms that are traveling down their legs. If it’s predominantly leg pain, well, I tell them I have a really good surgery to treat that, but if it’s predominantly back pain, I tell them that I probably am not going to make their back pain better, and then at that point, we really try to focus on non-surgical treatments and try to give them some pain relief.
Melanie: When we talk about – people hear the words minimally-invasive – and what does that mean, and what are some of the benefits of a minimally invasive procedure versus the traditional, more invasive procedures that you might have done in the past?
Dr. Tannous: Very good question. Everybody comes into the clinic, and everybody wants to know what this whole minimally invasive spine surgery is all about. Everyone wants the three-millimeter incision, and they want to avoid the bigger procedures. A lot has advanced in spine surgery over the past ten or fifteen years, but really over the past five years, as well. For some people – and I stress that – for some people, they are great candidates for a minimally invasive procedure. All that means is that we disrupt less muscle; we disrupt and take out less bone to accomplish the same goals.
The goals of spine surgery, first and foremost, when people have a neurologic deficit, you have to decompress the nerve. If you don’t decompress the nerve, you don’t alleviate the neurologic symptoms, and people don’t get relief of their leg pain or their quote-unquote – what people call sciatica.
Number two, if there’s any instability, you have to stabilize the spine. Traditionally, to do a spinal fusion to stabilize the spine, it used to be a big, open incision down the back and you spread all the muscles open to get down to the spine and do the work that you have to do. For some people, when the disease is so advanced, this is still the golden standard. This is still the way it needs to be done. There’s a significant subset of patients where we can accomplish the same goals, but instead of making a four or five-inch incision, we can potentially use a one-inch incision. But then again, it’s not really the size of the incision that matters; it’s how much muscle has been dissected off of the spine, and how much of the structures surrounding the spine have been disrupted in order to do the surgery. That’s really what the concept of minimally invasive spine surgery is. It’s not necessarily the size of the incision, but it’s how much of the dissection has taken place in order to accomplish that goal.
A really nice technology that has developed over the past ten years is doing spine fusions from the size as opposed to from the back. Coming from the side, there’s really very minimal muscle, you’re moving the bowel contents out of the way, and you pretty much have direct access to the spine without having to take down any muscle insertions. Versus having to do it from the back, you have to take down all of the big, robust, thick, paraspinal muscles that need to be dissected out of the way in order to access the spine.
And the same goes for decompressions. Traditionally, to do a decompression, you would go from the back and make a much bigger incision and then dissect all of the muscles out of the way. Today, we can do a lot of our decompressions through little tubes. The nice thing about these tubes is that instead of dissecting the muscles out of the way, you’re spreading them out of the way. You’re not damaging muscle fibers. You’re not ending up with high amounts of blood loss, so our techniques have become a lot more refined and a lot more targeted depending on which nerve is being pinched and where the pathology is in the spine – where the arthritis is in the spine.
Melanie: Dr. Tannous, you mentioned the word fusion, and right away, patients think, “Okay, now I’m not going to have any range of motion in my spine,” whether we’re talking about the neck, or cervical disk replacement, or in spine surgery. Are these motion preservation techniques? What can you tell them about what they can expect afterward?
Dr. Tannous: Excellent question. That’s another one of the major advances in spine surgery over the past ten years or so. Especially in the next -- not so much in the lumbar spine, yet. I don’t think we’re quite there yet with the technology -- but especially in the neck, the advent of cervical disk replacements has really changed, I think, the playing field for a lot of patients.
Traditionally, if patients came in and they had pinching of the nerves in the neck, the gold standard for relieving that pinched nerve and stabilizing the cervical spine – which is the neck – was to do what we called an anterior cervical diskectomy and fusion or an ACDF. What this is, is you go through the front of the neck, you move all of the vital structures out of the way, you take the disk out, you decompress the nerves in the spinal cord. You put a piece of bone in that spot, and then you stabilize it with screws and plates, and what happens over time is that bone will then grow into the bones in the spine.
For the most part, it still is the gold standard in 2017, but what’s nice now is that we have the option to do cervical disk replacements. For the right patient – and I won’t go into the details of who that right patient is – but in general, it tends to be younger patients who don’t have a lot of deformities, who don’t have a lot of arthritis, who have a pinched nerve. You can do the same thing. You can go to the front of the spine; you take the disk, you decompress the nerves. But now, instead of putting a piece of bone in there, you’re putting a mobile implant in there that essentially reproduces the natural motion of the neck.
The nice thing about that is that the one thing we know about spine surgery is that it isn’t just one joint. For example, in the neck, you have seven joints, right? There are seven levels. When people come in in their 30s, 40s, and 50s, to have one level addressed, there’s about a 3% chance per year that they’ll have to have another level addressed down the road. We think that cervical disk replacements are preserving the natural motion of the spine, transferring less stress to the other levels above or below, and potentially minimizing the risk of having to have another surgery down the road above or below the level where the disk replacement took place. It’s a very promising technology. It’s been FDA approved now for both One and Two-level disk replacements. In my experience, I’ve had patients have tremendous results.
Melanie: What do you see the future of spine surgery? What’s coming down the path?
Dr. Tannous: That’s a really good question. I think the future of spine surgery, as for medicine in general, is going to be an evolution and emerging of medicine and technology, especially with the technology. Robotics are advancing; navigation is advancing. Our ability to accomplish the same goals of surgery with smaller incisions, less invasive techniques, I think over the course of the next five or ten years, we’re really going to see technology and technique merge together.
At the end of the day, technology will never replace a good clinician. It will never replace someone sitting down and listening to the patient, and really understanding the story and coming up with the right diagnosis. It will never replace technical ability, but it will allow surgeons who have all of these abilities to really take it to the next level and minimize the treatment side effects and optimize patient outcomes. I think we’re at a very exciting time in the evolution of medicine, and I think we have a lot to look forward to in the next five or ten years. Especially in spine surgery where we’re just at the beginning of motion preservation techniques, and of minimally invasive techniques.
Melanie: Thank you, so much. It’s really great information, Dr. Tannous. Thank you for being with us, today. This is Medical Intel with MedStar Washington Hospital Center. For more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole, thanks so much, for listening.