Bigger is not always better, especially when it comes to spinal surgery. With continued advances in biologics and instrumentation and a continually evolving appreciation for the potential complications and dangers associated with major reconstructive spinal surgery, less invasive approaches are gaining popularity among spine surgeons and patients alike.
Lumbar Disc Herniation
Strong evidence supports surgery for recalcitrant lumbar disc herniation, but recent technological advances have changed how we think about surgically correcting this common problem. Traditional lumbar disc herniations are treated with diskectomy, in which the portion of disc that is pressing on the lumbar nerve roots is removed. However, the hole in the annulus fibrosus (through which the nucleus material initially herniated) does not automatically seal after diskectomy, which leaves the door open for another piece of disc material to potentially herniate and cause recurrent sciatica symptoms from a recurrent disc herniation.
Recent advances in tissue engineering have led to annular repair devices or sealants that can close the door on recurrent disc herniations. In addition to creating a mechanical plug for the annular tear, 3-D bioactive tissue scaffolds that can integrate into the remaining annulus may be able to promote new disc regeneration or biological repair of the annulus.
Spinal stenosis arises from pressure on the spinal nerves — attributable to lumbar disc herniations, facet joint hypertrophy, facet joint cysts or ligamentum flavum hypertrophy — and causes severe back and leg pain. Traditional surgery for lumbar spinal stenosis and spondylolisthesis (vertebral slippage) is decompressive laminectomy with or without spinal fusion. The potential morbidity of spinal fusion, especially in older individuals, has generated interest in less invasive methods to treat these disabling conditions.
For this fragile population, less invasive approaches that still allow for neurologic decompression while preserving spinal stability without the need for lumbar fusion have been championed. Recent examples of such technologies include interspinous spacers, interlaminar stabilization devices and innovative foraminal decompressive systems that preserve spinal stability even in patients with spondylolisthesis.
Biological Solutions: Stem Cells
One of the most exciting innovations in the treatment of degenerative lumbar disc disease is the potential for harvesting one’s own stem cells to facilitate disc regeneration, as opposed to disc removal and fusion, which are currently performed. While fusion and lumbar total disc replacement are both effective and standard treatments for degenerative disc disease, a more natural and elegant solution would capitalize on the regenerative power of stem cell technologies that promote disc regeneration or reverse the clock on disc disease. Numerous early clinical trials have shown great promise with these techniques, which may prove to be not only effective but also cost-effective.
Major spinal reconstructive surgery helps thousands of patients in the United States each year, but these procedures are not without exorbitant costs and serious potential medical complications. In both the present and near future, innovative lumbar spinal surgery techniques will continue to evolve to reflect the need for maximizing clinical outcomes, while reducing patient morbidity, complications and costs associated with current techniques.
Disclosure: Dr. Auerbach is a consultant to Paradigm Spine, LLC, which manufactures the coflex interlaminar stabilization device.