Disc herniations, impingements and more
Spinal disorders affect millions of people. The spine can be affected by arthritis, degenerative wear and tear problems affecting the joints and disks, as well as a variety of other abnormalities that cause pain, numbness and weakness. Problems in the low back or lumbar spine can affect the leg and foot, while problems in the cervical spine of the neck can affect the arms and hands.
Modern spinal care is very complex. When surgery is needed, patients should seek out highly trained experts. Dr. Aaron G. Filler is a former director of the Comprehensive Spine Program at UCLA and is an associate of the Institute for Spinal Disorders at Cedars Sinai Medical Center. He is the author of a widely read book about spinal problems from Oxford University Press and is one of the worlds leading experts in spinal surgery. Through the Center for Advanced Spinal Neurosurgery in Santa Monica, Dr. Filler offers a complete range of spinal surgery. His expertise includes fusion surgery and artificial disk surgery. In addtion, he specializes in the evaluation and treatment of patients who have already had spine surgery but who had a bad result from surgery. When pain and nerve symptoms are not relieved or are made worse by spine surgery, there is often a correctable problem that explains the failure and Dr. Filler is expert in finding what needs to be fixed.
To learn more about the many spinal disorders treated by Dr. Filler, please consult the information on this page. To request an appointment with Dr. Filler and the Institute for Nerve Medicine, please complete the contact form on this page.
Evaluation and Repair of Failed Spine Surgery
The reasons why some spinal surgeries fail usually fall into three categories:
Among the most significant problems facing a patient who has had a bad outcome after spine surgery is the difficulty of getting the original surgeon to identify what is wrong and correct it. Many spine surgeons prefer not to do any surgery on a patient who has had spine surgery once before.
At INM in Santa Monica, California, Dr. Aaron G. Filler is committed to helping patients with failed surgeries. Using advanced diagnostic imaging techniques, as well as new minimally invasive surgical methods, many difficult spinal problems can be solved.
Having completed an advanced Spinal Neurosurgery Fellowship and having personally developed several new treatment techniques, Dr. Filler can offer the best spinal neurosurgery available anywhere. He is committed to finding the solution to difficult spinal surgical problems.
Causes of Persistent Pain after Lumbar Discectomy
Animation: MR Neurography in patients with persistent radiculopathy after spine surgery.
(A) MR Neurography demonstrates flattening of the exiting nerve root (**) by a persistent fragment of disc material (fr) in the foramen. The contralateral nerve root (*) has a normal caliber.
(B) 36-year-old man with right S1 dysesthetic pain after microdiscectomy. Post-operative imaging showed good decompression, but the Neurography demonstrated persistent hyperintensity of the dorsal root ganglion (DRG) consistent with intraoperative mechanical trauma. No further surgical treatment was recommended.
Image Effects of Bone Spur Affecting the Spinal Root
Animation: CT/MR pair of images in patient wih hyperintensity and a bone spur.
(A) hyperintensity in a portion of the dorsal root ganglion (*) on MRI and
(B) a bone spur (**) on the corresponding bone CT images that physically contacts the site of hyperintensity in the ganglion. Taken together the images demonstrates that a surgically treatable small bone spur is probably responsible for the persistent symptoms.
(C) The MR myelogram shows hyperintensity in the root.
(D) The absence of filling in the X-ray myelogram confirms that the brightness is attributable to hyperintensity rather than to the presence of CSF.
Use of MR Neurography for Diagnosis of Routine and Unusual Spinal Pathologies
Animation: Adiculopathy exacerbated by lumbar spine instrumented fusion.
(A) 59-year-old woman with persistent severe left S1 radiculopathy exacerbated by lumbar spine instrumented fusion and not relieved by subsequent removal of the instrumentation. The image demonstrates perforation of the left S1 root by the course of the pedicle screw (ps). No further surgical treatment was recommended.
(B) Persistent sciatica after a fall with no improvement after discectomy. The image demonstrates inflammation around the nerve (S1) consistent with a sacral fracture (fx) abutting the foramen.
(C) The MR Neurography imaging protocol results in an MR myelogram as well as Neurographic images of the exiting nerve roots.
Distal Foraminal Impingement
Animation: Lumbar neurography for evaluation of sciatica of non-disc origin. Distal foraminal lumbar nerve root entrapment.
(A) Normal anatomy of the L3, L4 and proximal L5 nerve roots and lumbar spinal nerves as they exit the spine traveling in essentially linear fashion.
(B) Exiting right L5 nerve root (*) of 65-year-old woman with persistent right L5 radiculopathy after two spine surgeries. The course of the exiting root is distorted; there exists both focal narrowing and a region of hyperintensity (n).
(C) Myelogram of same patient obtained just prior to MR Neurography. The L5 root abnormality is too distal to be appreciated in the myelogram (*) and the study was read as showing a normal L5 root with no impingement. After the Neurographic diagnosis, the patient had a distal foraminotomy with excellent lasting relief of her radiculopathy.
Foraminal Impingement after Disk Surgery
Animation: Complete S1 spinal root and spinal nerve image demonstrating proximal right sided pathology and distal left sided pathology.
This case involves a 66-year-old woman with bilateral radicular symptoms and non-diagnostic lumbar MRI who did not improve after two decompressive lumbar spine surgeries.
(A) Anterior image plane demonstrated distal right S1 foraminal impingement with hyperintensity in the nerve root seen in A (*) and in B (**).
(B) Posterior image plane (3mm slices, no spacing) confirms hyperintensity in distal S1 root. The right proximal sciatic nerve is broadened and flattened at the sciatic notch with mild edema and increased caliber of fascicles. Her physical exam was consistent with a piriformis syndrome on the left only.
Post-Discectomy Nerve Root Inflammation
Animation: Post-discectomy radiculitis.
Two fascicles in the right S1 root are hyperintense as they descend from the root sleeve (A) and traverse the sacrum (B,C, D & E arrows).
The contralateral S1 root is normal in appearance. The patient experienced focal pain in the calf despite relief of other symptoms by microdiscectomy. There was no recurrent disc.
The symptoms resolved with a short course of dexamethasone.
Distal Foraminal Impingement – Additional Case
Animation: MR Neurographic image of exiting lumbar spinal nerve in foramen.
(A) Normal configuration showing the exiting spinal root as seen in routine myelogram, but also showing the configuration of the dorsal root ganglion and the proximal spinal nerve in the distal foramen which is not well seen in other imaging techniques.
(B) 74-year-old man with degenerative scoliosis and L4 radiculopathy. Myelography showed no evidence of nerve root cutoffs. The MR Neurography image demonstrated a severe stenosis in the distal foramen. His symptoms resolved with distal foraminotomy.
Complex Spine Surgery
Modern treatment for degenerative spine disease, spine tumors, infections, spine fractures and instabilities is considered to be complex spine surgery. Surgical treatment for these conditions may include minimally invasive microsurgical anterior and posterior approaches to the entire spine and often require fusion with titanium devices, bone grafts, pedicle screws, plates and rods.
With the use of the advantageous Stealth neuronavigation system surgeons are able to place titanium instrumentation devices with unparalleled accuracy.
This revolutionary technology and surgical skill offers patients faster recovery and minimizes postoperative pain and complications.
Minimal Access Spinal Technologies
When spine problems develop due to injury, aging, wear and tear, or deformity, treatment options should focus on the actual source of the problem with the least amount of interruption to a patients life. Medication, physical therapy, bracing or lifestyle changes may successfully treat problems caused by slipped discs, slipped vertebrae or curvature of the spine. For many people, though, surgery may be the best option to treat pain or deformity.
Open Surgery: The most beneficial aspect of traditional open surgery is the ability to see and access the spine easily. This type of surgery, however, involves long incisions, cutting and removal of muscle from the spine, and considerable post-surgical pain. Due to the large incisions and significant damage to the muscle, open surgery patients may experience hospital stays, recovery periods, scarring and pain that make this type of surgery daunting and exhaustive. Developing procedures that significantly reduce these effects through minimally invasive methods may allow patients to return to regular, active lives with less interruption and pain.
MAST: Minimally invasive procedures made possible by Minimal Access Spinal Technologies (MAST) potentially allow surgeons to successfully treat back pain and deformity with the least amount of interruption while achieving the same surgical objectives as open surgeries. These technologies have been developed out of the advances made in the field of orthopedic minimal access surgeries over the past two decades. Video cameras, x-rays, detailed anatomy imaging, computer-assisted navigation, specially designed instruments and precise diagnostic tools provide alternatives to conventional open spine surgery that may minimize patient recovery time and pain.
MAST procedures mean surgeons may achieve the same results and objectives of traditional surgery with imaging systems, tiny cameras and skin incisions no longer than thumbnails. Muscle is left intact and only separated, or split, along natural divisions to reach the affected area. Special live-action x-ray machines guide surgeons to exact locations on the spine, rendering moot any need to open the site for clear visualization and location of the spinal problem. MAST products provide surgeons the ability to work precisely in smaller surgical fields with significantly less tissue trauma. The potential patient benefits of MAST procedures can offer patients physical, psychological, emotional and aesthetic advantages that make surgery less daunting.
Potential patient benefits of MAST procedures:
CD HORIZON® SEXTANT Spinal System: The CD HORIZON® SEXTANT Spinal System allows surgeons to deliver and apply screw and rod implants to the posterior aspect of the spine without the major muscle and tissue disruption encountered with traditional spinal fusion surgeries. This minimally invasive technique potentially allows significant patient benefits.
Spinal Fusion: Spinal fusion is a process using bone graft to cause two opposing vertebrae to grow, or weld, together. To ensure position and rigid alignment while fusion takes place, surgeons apply spinal instruments, or implants, such as screws and rods to the spine. These implants are joined together to maintain spinal stability and are rarely removed. Spinal fusion and implants are used to restore stability to the spine, correct deformity and bridge spaces created by the removal of damaged spinal elements such as discs.
The Traditional Spinal Fusion Procedure with Implants: Traditionally, implants are applied directly to the spine through an open approach requiring incisions up and down the middle of the back. Large bands of back muscles are stripped free from the spine and pulled off (retracted) to each side for visualization of the spine and easy access to the bones for instrument implantation. This stripping and retraction can cause considerable back pain, and the muscles, to some degree, are permanently scarred and damaged.
How CD HORIZON SEXTANT System Works
Who Can Benefit From CD HORIZON SEXTANT
Clinical Experience: While still a new technology, several preliminary studies have indicated the potential accuracy and reliability of the CD HORIZON SEXTANT Spinal System. A recent study [J Neurosurgery: Spine 2002; 97:7-12] followed 12 patients who underwent pedicle screw fixation using the CD HORIZON SEXTANT Spinal System. The system was used in each case to accomplish an instrumented posterior spinal fusion. After completing the surgery, the patients were followed for an average of 13.8 months. Results were classified according to modified McNab criteria, which measure surgical outcomes on a poor to excellent scale. The study results include:
METRx MicroDiscectomy System: The unique, muscle-splitting METRx MicroDiscectomy System provides access to the spine with less tissue trauma than associated with traditional surgeries to relieve pressure on nerves. Posterior approach procedures with this system offer significant potential benefits.
Discectomy: A discectomy removes a disc herniation (bulging disc) to relieve pressure on an adjoining nerve.
A traditional open discectomy requires a large (up to four inches) incision down the middle of the back with extensive stripping of muscle from the spine to get to the affected disc. Though using one-inch skin incisions, newer microsurgery discectomies still involve cutting muscle and scraping it from the spine to access the disc. The muscle damage of these surgeries contributes to most post-operative pain and longer, more difficult rehabilitation periods
The METRx MicroDiscectomy System is composed of bayoneted surgical tools with various-sized metal tubes used to create and maintain openings to spinal elements. Fundamental to this system are specially designed metal tubes, called dilators, which progressively increase in diameter size. These dilators are inserted sequentially smaller to larger through the muscle to gradually separate, or split, and open the muscle to create an opening large enough for surgical tools to be used. The systems retractor tubes maintain the opening while the surgeon uses specially designed surgical tools to reach and remove spinal elements that are causing pain.
The Minimally Invasive Approach with the METRx
Surgeons are able to precisely locate, see and remove herniated discs in the spine through tunnels created by tubes that split back muscle, much like a sewing needle splits the weave of fabric, along natural divisions. No muscle fiber is cut, only separated. This unique muscle-splitting approach allows surgeons to access the spine with a posterior approach without cutting or removing muscle from the spine. How it works:
Who can Benefit from METRx MicroDiscectomy System
Clinical Experience: The METRx System represents a new area in spine surgery, and the results of surgeries performed with this system have yet to be fully studied. However, in a preliminary study of 26 patients who had a lumbar discectomy with the METRx System, all reported very high levels of satisfaction with the procedure. In addition, patients in one study stayed in the hospital for an average of 12.1 hours, with a range of two hours to 48 hours. This compares favorably to the two to four days needed for open procedures.
In terms of relief of symptoms related to unpinching the nerve root, surgical outcomes using the METRx System are comparable to open procedures. However, since the METRx System allows the surgeon to unpinch the root without cutting or stripping muscle, patients are offered several advantages in terms of post-operative pain, recovery period, rehabilitation and cosmetic results.
Request an appointment with Dr. Aaron Filler
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Dr. Aaron Filler is the world’s leading expert in the treatment of nerve pain, revolutionizing this area of medicine by inventing several new technologies. One such technology, MR Neurography, enables doctors to use an MRI scanner to examine nerves, previously a difficult-to-impossible tissue to visualize with MR imaging. Dr. Filler’s research in axonal transport is leading to a whole new generation of advanced pain medications. He has developed many new “minimal access” surgery methods that allow him to treat complex nerve problems with small outpatient surgeries. He has also pioneered the use of the Open MRI scanner to do surgeries and other therapies with the ultra-high precision and safety of the magnetic resonance imaging.
Dr. Aaron Filler combines three key components in his treatment of each patient:
He combines these components to turn insoluble pain problems into specific treatable diagnoses. Prior to coming to the Institute for Nerve Medicine, many of Dr. Filler’s patients have seen a dozen doctors (or more), experienced failed surgeries, and have even had their very pain questioned.
Time and again, Dr. Filler demonstrates that in many of these cases the problem is the doctor and not the patient. A cure is in reach when the best available medical care is brought to bear.
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