Highly trained specialists and subspecialists at Neurological Surgery P.C. (NSPC) tailor treatment plans, from minimally invasive spinal fusion surgery to percutaneous and open procedures, to meet the needs of patients in a convenient setting close to home.
When it comes to spinal surgery, one size does not fit all — a concept that the neurosurgeons at NSPC embrace. Thanks to the wide range of procedures these surgeons perform and their partnerships with local practitioners, Long Island patients receive treatment plans customized for their individual needs. Treatment options may include nonsurgical therapy, minimally invasive or open surgical procedures, rehabilitation services, and more to address spinal issues and related conditions.
“All of the surgical techniques we use are modular — they can be mixed and matched or combined to create extensive and complicated spinal constructs that would have previously been performed in an open fashion alone,” says Alex Zouzias, MD, Specialist in Complex and Minimally Invasive Spinal Surgery at NSPC. “Because we’ve mastered these techniques, we can offer personalized treatment plans for each patient.”
Depending on the diagnosis and health of the patient, specialists at NSPC may initially recommend nonoperative treatments from area practitioners (see Local Collaboration). These approaches may include physical therapy, acupuncture, steroid and anesthetic injections, and chiropractic pain management.
“I don’t use the term ‘conservative’ when referring to these treatments because that implies surgery is radical, which it’s not,” Dr. Zouzias says. “However, we do maximize nonoperative therapy whenever possible. Many of the conditions we treat have excellent responses to nonoperative measures. These measures also help with patient expectations and compliance with surgical treatment and follow-up because patients understand they’ve exhausted other treatment routes by the time they require surgery.”
Xavier Gaudin, DO, neurosurgeon with dual training in neurosurgical and orthopedic spine surgery at Neurological Surgery P.C., spends time educating a patient and reviewing treatment plans.
Best of Both Worlds
The availability of both minimally invasive and open surgical procedures is especially important in treating spinal disorders. The specialists at NSPC evaluate each case to determine the optimal approach.
“For example, when doing routine decompression of the spinal cord or nerve roots, or performing in situ instrumented and interbody fusion, a minimally invasive procedure is often the most efficient,” says Xavier Gaudin, DO, neurosurgeon with dual training in neurosurgical and orthopedic spine surgery at NSPC. “However, for adult spinal deformity or focal alignments correction, an open approach may be indicated, especially if it requires major realignment of the spine by performing osteotomies and removal of arthritic or previously fused facet joints.”
A patient’s age, overall health, comorbidities, lifestyle and personal wishes are important factors in Dr. Gaudin’s and Dr. Zouzias’ choice of minimally invasive or open procedures for conditions such as degenerative scoliosis, spinal stenosis and compression fractures.
“Every patient is unique, and the decision on how to approach the specific disease process has to be made by an experienced spine surgeon,” Dr. Zouzias says. “However, what we’re seeing is that more and more cases that would have required open surgery in the past can now be approached minimally invasively with excellent results.”
Minimally invasive surgery can also provide treatment options for older patients who cannot undergo an open procedure safely or for younger patients who wish to return to an active lifestyle quickly. The decreased pain and reliance on narcotic medications after minimally invasive surgery allow patients to begin physical therapy and return home within two to four days rather than a week.
“The goal is to have patients start ambulating and receiving therapy as soon as they can tolerate it and it is medically safe,” Dr. Gaudin says. “Rehabilitation is really when the healing occurs and patients start to improve.”
Alex Zouzias, MD, Specialist in Complex and Minimally Invasive Spinal Surgery at Neurological Surgery P.C., discusses a planned spinal fusion with a patient in clinic. Communication between patient and physician is key for successful outcomes in spine surgery.
Spinal fusion is one of many procedures that can be performed minimally invasively at NSPC. Appropriate for certain cases of spinal stenosis, scoliosis and related conditions such as sciatica, minimally invasive spinal fusion reduces surgery-related bleeding as well as postoperative pain, recovery time and risk of infection.
This approach — through the side of the body — allows surgeons to access affected areas of the spine through two small incisions, bypassing muscle dissection.
“That is much better tolerated from a pain and recovery standpoint,” Dr. Gaudin says, “because we’re going through natural muscle planes and corridors of the body.”
During minimally invasive spinal fusion to treat spinal stenosis, nerves are decompressed and an interbody cage is used to fuse two vertebrae.
“I insert a small tube on the side directly over the stenosis, which allows me to leave the posterior ligament tension band intact,” Dr. Gaudin says. “This helps maintain the overall integrity of the spine, which can prevent destabilizing segments and the need for more complex surgery down the line.”
Herniated disks, which can also compress the nerves in the spine, can be removed during a minimally invasive procedure as well, so long as no instability is found in the spine.
For patients with extensive degenerative scoliosis or spinal deformities, an open approach to spinal fusion may be indicated to better allow for complex surgical techniques, such as osteotomy.
“Arthritic wear and tear and aging can cause our backs to become abnormally kyphotic, or hunch forward,” Dr. Gaudin explains. “As a natural mechanism in attempting to maintain stability, the spine will form bridging bones to halt this process. In order to correct this stiff malalignment of the spine, it requires the release of these bridging osteophytes and autofused facet joints, which is more appropriately done in an open fashion in most cases.”
Close-up of the spine model, demonstrating the final construct for an anterior cervical discectomy and fusion, one of the most common surgeries performed by spine specialists
Though certain spinal deformities require open surgery, compression fractures of the spine can usually be treated percutaneously. Percutaneous screws are strategically placed to hold the spine together while the compression fracture heals, avoiding the need for external bracing and preventing spinal deformity.
“We insert percutaneous screws above and below the unstable segment of the spine and connect them with a rod — all accomplished by a minimally invasive approach,” Dr. Gaudin says. “This is done using fluoroscopy and neuronavigation. Neuronavigation tools let us visualize the surgery we’re performing underneath the skin through a monitor, thereby allowing us to keep the soft tissues intact.”
Percutaneous balloons can also be used for older patients to treat areas of the spine that have weakened and collapsed due to osteoporosis.
“Elderly patients can’t tolerate open spinal surgeries, so we place an inflatable balloon using percutaneous techniques and inflate the collapsed bone,” Dr. Zouzias says. “Then, we inject the space with methyl methacrylate, a type of bone cement, and stabilize the fracture. This provides immediate pain relief and can be performed as an outpatient procedure, ideally with light sedation and no general anesthesia.”
In some cases, spinal metastatic lesions can be destroyed percutaneously using thermal ablation. Though this is not curative for patients with widespread cancer, it provides significant pain relief.
Pre- and postoperative images from a minimally invasive spine fusion performed for lumbar spondylolisthesis — slippage of the vertebral bodies — in a patient with gross spinal instability. All instrumentation was placed using incisions less than 2 centimeters long.
Cervical Artificial Disk Replacement
Another advanced surgical option that NSPC offers is cervical artificial disk replacement. This technique allows surgeons to treat damaged disks within the spine without resorting to anterior cervical fusion. Though the latter technique is indicated in some cases, it can limit the degree of movement in the neck and apply stress on other segments of the spine.
“Anterior cervical fusion can lead to more disks breaking down and may require a cascade of reoperations to extend the fusion,” Dr. Zouzias says. “Cervical artificial disk replacement has been statistically shown to prevent this adjacent segment degeneration and can lower the chance of further surgery.”
Though cervical artificial disk replacement is considered an open procedure, it requires no dissection of muscles and can be performed as a same-day surgery. It is typically more appropriate for younger patients who have one or two levels of disk herniation, live active lifestyles and want to return to their activities without the need for a cervical collar, which is normally required after cervical spine fusion.
“You have to restrict activities for bones to fuse, but with this procedure, we can encourage patients to be active, which allows the artificial disk to begin moving properly,” Dr. Zouzias says. “Home and outpatient physical therapy are an important part of any postoperative surgical game plan.”
Drs. Zouzias and Gaudin review films in preparation for a case involving complex spinal reconstruction.
Open and Shut
NSPC specialists perform open surgery for cases such as revisions, tumors and infections.
“Infections are becoming a more common cause of spinal deformity that we see,” Dr. Gaudin says. “Spinal abscesses can erode through bones of spine and cause these deformities. Typically, we want to perform open surgery to aerate and generously remove as much of the abscesses as possible, then place drains and topical antibiotics. Introducing air and oxygen will help kill bacteria.”
For cases in which spinal tumors cause stenosis, Dr. Gaudin frequently relies on open surgery to lower the risk of nerve damage, though smaller tumors can be addressed with minimally invasive procedures in some instances.
“If the goal is not to completely resect the tumor, but rather to debulk the tumor for biopsy, or decompress the spinal cord and create a margin so that radiation and/or chemotherapy treats the rest, then minimally invasive options may be appropriate,” he says.
Revision surgery also typically requires an open approach, especially when scar tissue is involved.
“When you’re operating adjacent to a spinal level that had previous surgery, you can perform a minimally invasive approach as long as you’re going into a virgin territory,” Dr. Gaudin says. “However, when you are dissecting through scar tissue, an open procedure is indicated because you no longer have the natural corridors within the tissue and may be dealing with prior hardware or pseudarthrosis that needs to be addressed in a more complex manner.”
During most revision procedures, Dr. Gaudin is addressing pseudarthrosis, or bone that hasn’t healed or fused. When patients develop this condition, existing screws or rods may become loose and need to be removed and replaced with stronger and newer hardware. Scar tissue must be removed for this complex procedure.
“Fusion cannot form over scar tissue,” Dr. Gaudin says. “It requires meticulous work to dissect the scar tissue, expose fresh bone surface, then re-arthrodese by drilling and placing donor bones and special proteins that induce bone formation.”
Local Specialization and Teamwork
NSPC is made up of a large group of specialists and subspecialists — more than 20 in total — many of whom have experience at academic hospitals.
“We have substantial amounts of resources, specialty centers and projects similar to academic institutions,” Dr. Gaudin says. “Even for our most routine cases, we use the latest cutting-edge technologies and employ a two-surgeon approach.”
That means neurosurgeons frequently perform procedures alongside an orthopedic partner. This allows for more efficient surgeries, reducing the chance of complications. Surgical time can be cut in half in some cases.
“For patients, less time in the OR is always better,” Dr. Zouzias says.
Neurosurgeons and orthopedic surgeons also enhance a patient’s course of treatment by discussing surgical plans prior to performing complex procedures.
With six locations across Long Island, area patients have quick access to spine specialists without enduring long travel times to Manhattan, which can be especially problematic for patients experiencing back pain. Further, attending physicians are available at NSPC for inquiries via phone for patients and referring physicians, including on weekends.
“For the minority of patients for whom nonoperative treatment is insufficient, it’s important that they be referred to a spine specialist who is well-versed in both minimally invasive and open techniques,” Dr. Zouzias says. “Patients should be provided with the broadest spectrum of options at an established, subspecialized practice that can provide the highest level of care.”
Visit nspc.com for more information.
Photos © Don Dempsey, White Light/Spartina Studios