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 [email protected]. 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 Things are looking good for neurosurgery in Texas. Texas Spine and Neurosurgery continues to expand. We have started doing ALIF(anterior lumbar interbody fusion) procedures in multiple locations and we were recently the first in the country to use a particular titanium 3D printed interbody cage in an ALIF.
Our new building is ready for move in. Texas Spine and Neurosurgery will be moving to our new head office on August 24. We will be expanding from 2400sq feet to 9850sq feet with 8 exam rooms and significant office space for expansion. Our new location will be 4515 Lakeshore drive. The new building is undergoing major renovations including an elevator upgrade. This move is very exciting for all of our team. It will allow us to provide exceptional care to all our patients in a much more comfortable environment. There will be more than ample parking and we will have room for growth of our team and the addition of further healthcare providers for years to come. Presently, construction has begun on new ADA compliant bathrooms and the elevator.
When conservative therapy fails and surgery becomes the next option, there are several potential surgical options for the lumbar spine. One surgical approach is the Anterior Lumbar Interbody Fusion, which, in most circumstances, is followed by a Posterior Lateral Fusion for more rigid fixation.
ALIF (Anterior Lumbar Interbody Fusion)
The procedure we use consists of a retroperitoneal approach with an incision typically on the left lateral side of the abdomen. The incision is typically 2 inches long. The surgeon navigates to the spine through the lateral abdominal muscles consisting of the obliques. These muscles are split and are able to be easily retracted as opposed to being cut. A dilator is placed over a guide wire and a retractor is placed. The psoas is visualized and stimulated to determine the location of any nerves. The psoas is then split and retracted. The average blood loss is 25ml per level. This approach allows access to the spine without significant trauma to the muscles or neural structures. Once the disc is visualized, the intervertebral disk is removed from the disk space and a PEEK or titanium interbody implant is placed between the two vertebrae. The cage is filled with bone graft material to promote fusion. This procedure facilitates fusion of the vertebral bodies and disk space. The fusion process takes a few months to occur during which time the patient’s bone will grow in and around the new interbody implant. A much larger interbody implant can be placed using this anterior approach compared to a posterior approach, which in turn leads to better stability of the fusion. This procedure takes about an hour with less than 60 seconds of flouro time. The patient usually goes home the next day however they can go home the same day depending on how they feel post surgically. The patient is discharged with a lumbar brace. The patient will return for a second posterior approach to better stabilize the spine with instrumentation.
We have been performing this procedure on patients at many of our locations and have had very good outcomes. Please contact us if you have a patient who might benefit from this procedure.
Below are pictures of a revision surgery. The patient had previous instrumentation at L4-S1. ALIF was performed at L2-3 and L3-4. Later a PLF was performed and extended the patient’s fusion from L4-S1 up to L2.
(Image 1: Dr. Zielinski and his team in the OR. Image 2: Lateral view of an interbody cage. Image 3: AP view of an interbody cage. Image 4: Lateral view of a 2 level L2-4 ALIF on a patient who had a previous Lumbar Fusion at L4-S1.)
References:
North American Spine Society (NASS). Diagnosis and treatment of adult isthmic spondylolisthesis. Burr Ridge (IL): North American Spine Society (NASS); 2014. 87 p. [488 references]
Ullrich, P. F., & J. (n.d.). Anterior Lumbar Interbody Fusion (ALIF) Surgery. Retrieved July 5, 2018, from https://www.spine-health.com/treatment/spinal-fusion/anterior-lumbar-interbody-fusion-alif-surgery
Product Review: TENS Unit
Ms. Kourtney Cummings, Clinical Liason
Most patients with back or neck pain begin their treatment with conservative treatment measures. These conservative measures may include physical therapy, epidural steroid injections, opioids, NSAIDs, chiropractic therapy, massage therapy, and acupuncture. These options can be helpful and important, but also costly and time consuming. For some patients, something as small as a TENS unit can provide great relief without leaving the house.
A transcutaneous electrical nerve stimulation unit is a device that uses electrical impulses that reduce the sensation of pain. It is a device that can be used for neck pain, back pain or extremity pain. Electrodes are placed on the skin and the electrical current decreases the pain signals. Exactly how a TENS unit works is not completely understood, however, it is believed that the TENS unit works by the gate control theory of pain. The gate theory of pain explains how non-painful stimulus is able to suppress the painful input. Another theory is that by stimulating nerves it may be causing the body to produce endorphins, which are the body’s natural painkillers.
The TENS unit works by placing adhesive pads on the skin over the area that is painful. Studies have shown that placing the electrodes over acupoint sites may increase analgesia. The unit is turned on and an electrical impulse is sent from the unit and an electrical sensation is felt. The TENS unit has different settings to control the intensity of stimulation. It has been shown that the TENS unit is most effective when used on the strongest intensity that remains comfortable, which produces hypoalgesia, a decreased sensitivity to painful stimuli.
TENS units are a great device and option for those trying to control their pain with conservative measures. Besides the advantage of pain relief, TENS units do not carry the side effects of pain medications and other pharmaceuticals. They do not require a repetitive cost and can be used at the patient’s convenience.
Vance, C. G., Dailey, D. L., Rakel, B. A., & Sluka, K. A. (2014). Using TENS for pain control: the state of the evidence. Pain Management, 4(3), 197–209. http://doi.org/10.2217/pmt.14.13
The gate control theory of pain. (1978). British Medical Journal, 2(6137), 586–587.
Student Corner Deep Brain Stimulation
Hailey Fox B.S., Bethany Gray B.S.
Deep brain stimulation (DBS) is a treatment that involves the surgical insertion of an electrode into a particular brain region to modulate neural activity in the area. An extension of this wire is then inserted and passed the neck and should areas to the Internal Pulse Generator, which sends electrical pulses up the wire and into the brain.
During surgery, the patient remains awake and alert, allowing the surgeons to monitor their cognitive functioning. The designated regions of the brain are located through unique computerized brain mapping technology. After recovery, patients are given a magnet to calibrate the IPG strength, depending on their needs. If a patient is aware of events such as auras preceding seizures, the individual may even wave an electronic device such as a cell phone over the stimulator in the chest, causing electrode to alter regional activation, preventing or modulating neurological event.
This incredible technology has been proven effective in treating and managing symptoms of Parkinson’s, seizure disorders, dystonia, Tourette’s, and even Obsessive-Compulsive Disorder. The patient’s physician can monitor and receive feedback from the device, including abnormal neural activity, which aids in diagnosing neurological disorders and identifying seizure patterns.
Since the FDA approved DBS as a therapeutic device for Parkinson’s Disease in 1997, it has become increasingly popular and clinical research using it for dozens of other disorders and syndromes has become quite common. The scientific community is still unsure what the exact mechanism is that makes DBS so effective. It does not “cure” any disorders, but it dramatically reduces symptoms. Some hypothesize that the electrical currents block the neuronal output at or near the electrode site, which aid in reducing symptoms of neurological disorders. Others have said the symptom reduction is a result of synaptic inhibition. Another popular theory is simply that the device de-synchronizes any abnormal activity of neurons.
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 [email protected]
www.txspineonline.comFor back issues of the journal please see our web page.
http://dev.txspineonline.com/texas-spine-and-neurosurgery-journal/
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.
