December 2018
The Texas Spine and Neurosurgery Journal
The goal of this academic publication is to inform and educate physicians and their staff about spine care and neurosurgery.
A Word From The Editor
Steven C. Zielinski, MD, CM, FRCSC
Diplomate of the American Board of Neurological Surgery
Welcome. This is our second year in publication. Our goal is to aid and inform family doctors and community providers as well as their staff. We want to help practitioners treat their patients with spine and neurosurgery issues.
We are continuing to expand! If you would like to contribute, if you know of someone who might benefit from a subscription, or if you have a question or topic for review, please contact us at info@txspineonline.com. The territory for the Journal continues to grow, but presently extends from Mineral Wells to the Gulf coast and from Stephenville to Nacogdoches.
Update from Dr. Z
Happy Holidays!!!!!
Things are looking good for neurosurgery in Texas. Texas Spine and Neurosurgery continues to expand. We have moved into our new building on 4515 Lakeshore drive. All inspections are complete and we are fully ADA compliant. In 2019 we will be undergoing further expansion. There are plans to purchase and renovate 2 other offices in our busy satellite regions. We will keep you posted as news becomes available. Also, our entire team would like to wish everyone a Happy Holiday!
Expert Opinion:
Physician Assistant Insights
ALIF procedure from a Posterior Oblique Retroperitoneal approach (also known as Oblique Lateral Lumbar Interbody Fusion – OLLIF)
Ms. Ashley Sullivan, MSPAS, PAC
The OLLIF is a minimally invasive procedure that was developed by Spinal Elements that allows for the placement of an interbody cage with little back pain post-surgically. Patients typically stay in the hospital for about 23 hours. There is typically 5-10 cc of blood loss.
This procedure is a retroperitoneal approach that involves the patient being placed prone and the incision is posterior lateral. The incision is typically a few centimeters in length. With the combination of X-ray (AP and Lateral) and neuromonitoring the surgeon navigates to and through Kambin’s Triangle to the disk space using a probe that has a neuromonitoring attachment. Once at the disk space, as indicated by X-ray, and safely past the exiting nerve root, a guide wire is inserted. The dilator, followed by the portal are positioned into the disk space. The disk space is opened and a discectomy is performed using a flexible currete and pituitary. A sizer is placed to determine the size of the permanent cage that will be placed. The disk space is prepped and bone graft is placed in the disk space. A guide wire is reinserted and the portal is removed. The expandable cage is inserted by being threaded over the guide wire into the disk space. The cage is expanded into place (torque limited by pressure) and then the cage is disengages from the inserter.
Like the ALIF procedure described in last quarter’s journal, this procedure takes less than an hour and the patient goes home the next day. The patient goes home wearing a brace. In some cases the patient returns the next week for a second posterior approach to better stabilize the spine with screws and rods.
We have been performing this procedure on patients at many of our locations and patients are doing very well.
(Image 1: Kambin’s Triangle. Image 2: Amendia expandable cage. Image 3: AP view of a 5 level OLLIF. Image 4: Lateral view of a 5 level OLLIF. Image 5: Two level OLLIF showing the expansion of the cage.)
Intraoperative Neuromonitoring
Dr. Zielinski has been using intraoperative neurophysiological monitoring to ensure the safety of the nerves and spinal cord during surgery. Intraoperative neuromonitoring uses EMG to monitor, localize, and test the functions of the neural structures. During ALIF and OLLIF cases in particular, neuromonitoring is used to map areas of the nervous system to guide how to approach the disk space and avoid injuring any nerves that are in close proximity to where we are working. The neuromonitoring probe stimulates at certain distances. During the OLLIF cases, we stimulate at certain distances. 4 mAmp is the standard distance and correlates to the distance of a nerve root. 4 mAmp is needed for safe corridor. During an ALIF procedure we can stimulate at threshold to find the nerves.
Reference: Surgical Technique Guide. Amendia. Performed by Dr. Ashish Sahai, M.D. , FAAOS. Spine & Orthopedic Center
280 SW Natura Ave
Deerfield Beach, FL 33441
Neuro Monitoring
Steven Zielinski MD CM
Spinal and cranial surgeries carry a documented risk of injury to the spinal cord, spinal/peripheral/cranial nerves and/or blood vessels. Consequently, multi-modality intraoperative neuromonitoring has become standard of care across most of the U.S. [ CITATION Pic16 \l 1033 ]. Multimodality IOM is the utilization of different modalities in combination such as somatosensory evoked potentials (SEP or SSEP), trans-cranial motor evoked potentials (TcMEP or MEP), sensory nerve action potentials (SNAP) and electromyography (EMG). Multimodality IOM is how neurophysiologists maximize the reliability of findings related to the neural structures at risk, which in turns keeps surgical maneuvers within safe limits and prevents iatrogenic damage.
Neurological deficits, such as paralysis, muscle weakness, pain, bladder/bowel disturbances and sexual dysfunction, which emerge post-operatively, can seriously affect basic human functions, activities of daily living (ADL’s), and increase morbidity[ CITATION Gho15 \l 1033 ]. IOM allows monitoring of the following: spinal cord (SSEPs and MEPs), the nerve roots (sEMG, tEMG) as well as plexuses, peripheral nerves and all relevant vascular supply to these structures.
In the early 1980’s, patients were frequently admitted to inpatient rehabilitation units with neurological deficits post-op from spinal surgery. This number has significantly decreased since then due to improved surgical techniques, as well as from IOM. To illustrate the efficacy of IOM, a study from Tamkus, Rice, and Kim (2017) notes that many non-catastrophic injuries are recoverable when detected and treated in a timely manner. The authors further note that “80% of patients, for whom a surgical intervention was enacted based on an IONM alarm, showed recovery of their postoperative neurologic deficits by the time of discharge compared with only 20% of patients in whom no surgical intervention was performed” (p. 285).
References
Ghobrial, G., Williams, JR, K., Arnold, F., & Harrop, J. (2015). Iatrogenic neurologic deficit after lumbar spine surgery: A review. Clinical Neurological Neurosurgery(139), 76-80.
Pickell, M., Mann, S., Chakravertty, R., & Borschneck, D. (2016, September). Surgeon-driven neurophysiologic monitoring in a spinal surgery population. Journal of Spinal Surgery, 173-177.
Tamkus, MD, PhD, DABNM, A., Rice, MS, K., & Kim, MD, H. (2017, December). Intraoperative Neuromonitoring Alarms: Relationship of the Surgeon’s Decision to Intervene (or Not) and Clinical Outcomes in a Subset of Spinal Surgery Patients with a New Postoperative Neurological Deficit. The Neurodiagnostic Journal, 57(4), 283-284.
Our History
The “Texas Spine & Neurosurgery Journal” was founded by Dr. Steven Zielinski, a Stanford trained neurosurgeon who believes in giving patients the freedom to control their own healthcare, in partnership with their chosen physician. Texas Spine and Neurosurgery is a patient centered practice that brings first class spine care to local communities and to patients. Texas Spine and Neurosurgery started as a small collaboration with local hospitals and local providers and has grown over several years. Today, we have relationships with a vast array of outstanding hospitals and surgical centers. We coordinate care with the best specialists in different aspects of conservative care throughout Texas. In order to continue these efforts Texas Spine and Neurosurgery is a proud sponsor of the Texas Spine and Neurosurgery Journal. It’s focus is to educate and inform community physicians and family doctors in Texas and beyond about relevant topics in spine and neurosurgery.
If you have questions or comments or wish to contact or refer a patient to Texas Spine and Neurosurgery or one of our Physician contributors please contact us.
1 (844)Meet DrZ
1 (844)633-8379
Info@txspineonline.com
www.txspineonline.com
For back issues of the journal please see our web page.
http://dev.txspineonline.com/texas-spine-and-neurosurgery-journal/
Copyright © *|2016 Texas Spine and Neurosurgery, All rights reserved.
Texas Spine and Neurosurgery and Texas Spine and Neurosurgery Journal
are the property of Steven Zielinski MD PA, DBA Texas Spine and Neurosurgery.
All articles reflect the opinions of the individual authors and are not independently verified for accuracy. The Journal provides no recommendation for therapy of any individual patient but tries to promote the academic discussion of the topics covered.
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4515 Lakeshore Drive
Waco Texas,
76710
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