JOIMAX, a world leader in minimally invasive spinal surgery technology will be launching a new endoscopic system for neck surgery on April 3rd to 5th at the International Society of the Advancement of Spine Surgery (ISASS) meeting in Vancouver, BC. This advanced surgical system called CESSYS (Cervical Endoscopic Surgical System) will provide an alternative to traditional open neck surgery and will change how neck surgery is done in the future!

Cervical disk herniation is a common cause of pain, stiffness, numbness and weakness. Traditional neck surgery involves a large incision, retraction of the voice box and food tube, removal of the entire disk, and fusion that may produce ugly scars, hoarse voice, swallowing difficulty and stiffness at the fused level. Cervical fusion also may involve future neck pain and surgery because the remaining disks must compensate for the fused level and may become damaged from excessive movement. An enormous amount of research has been focused on this adjacent level disease.

The artificial cervical disk was developed to avoid fusion and prevent adjacent level disease and future surgeries. Even though the artificial disk was welcomed with great enthusiasm, long-term results are unknown, and there is concern for the longevity of these man-made disks. Minimally invasive posterior cervical discectomy was another approach developed to avoid fusion and subsequent adjacent level disease, although unfortunately, most disks are not approachable through the back of the neck. This has led to development of an endoscopic discectomy through the front of the neck, similar to, but less invasive than the traditional open neck surgery.

Endoscopic spine surgery has become a popular alternative to traditional spine surgery. The endoscope is a pen-sized, high-definition video camera that is inserted into the spine under x-ray guidance. The endoscope allows the surgeon to find and remove the herniated portion of the disk under direct visualization with very tiny instruments, relieving pain and suffering. Advantages of endoscopic surgery include a tiny skin incision, minimal tissue damage and pain, quicker recovery and same-day discharge.

JOIMAX designed the CESSYS cervical endoscopic surgery system to minimize tissue damage and be versatile enough to remove most disk herniation without the need of fusion, with the objective of decreasing the need for future surgery. The CESSYS cervical endoscopic surgical system will be available in the United States in the fall of 2013 to select JOIMAX instructors and faculty, including Dr. Carl Spivak.

July 9, 2014
Several of my patients have asked me if losing weight could help take pressure off of their spine and help ease their back pain. The answer is slightly more complex than a simple yes or no. Simply losing weight through the alteration of diet could diminish muscle mass, which could actually lessen the support that the spine is receiving.

On the other hand, a healthy diet when combined with a mixture of strength training and low impact cardio can help build new muscle and support the existing muscle while losing fat. As muscle is higher density than fat, the scale might not accurately predict the changes occurring in your body. It is important to track measurements with a tape measure as well as weighing in on the scale.

Resistance training is very important to helping minimize back pain. Strengthening the muscles of both the back and abdomen help to support the spine and decrease back pain. Strong muscles in the torso can do quite a lot to help support a compromised spine. Mobility training such as yoga or pilates can help increase flexibility and range of motion in those who have back pain or who have had back surgery. Exercise that is too fast or high impact should be avoided, as well as activities that involve twisting the torso.

As every patient is different, it is important to consult your doctor or physical therapist before you begin a new exercise routine. They should be able to tell you specific exercises that could help, as well as those you should avoid.

Can Zumba Hurt My Back?

by Carl Spivak

July 7, 2014
Recently I have had a couple patients ask me if they could participate in Zumba classes without putting their backs at risk. Unfortunately, I cannot recommend this low-impact dance aerobics class for those with a bad bad or those who have undergone back surgery. Even though it is low impact, it is fast paced and often performed on a hard surface. The quick movements, many of which twist the spine, combined with a hard surface can do much to throw off the alignment of the spine and exacerbate existent back problems. Zumba can also damage the back by increasing the pressure of existent muscle, skeletal or postural imbalances. For these reasons, I generally do not recommend that my patients take Zumba classes unless they already had a vigorous fitness routine that would help their body adapt to the movements of Zumba.

Other exercises I recommend to my patients who have undergone spine surgery or who are receiving treatment for back pain include Pilates, Soul Cycle, Restorative Yoga, swimming, walking, and resistance training with weights or bands. Low impact exercise is generally best for those with back problems, but low impact is not the only thing to consider, as we can see with Zumba. High speed twisting of the torso is not advisable for a spine patient. Pilates often involves twisting, but at a slower speed and more control. If you have any doubts about whether an exercise or workout is appropriate for you, it is best to check with your doctor to be sure. While a good workout can help your back pain, choosing the wrong one can do significant damage.

June 22, 2014

I see many patients who suffer from sciatica. These shooting pains in the lower back and legs can be debilitating. Sometimes surgical treatment is necessary to relieve this pain, but sometimes it can be brought under control or even eliminated with the proper exercises. Sometimes patients can be treated non-surgically with anti-inflammatory medications and pain relievers or steroids. These non-surgical treatments for sciatica are often paired with physical therapy so that the body can be trained to support the spine and protect the back from further damage or recurrence of sciatica. A program of gentle stretching and strengthening can often be paired with massage to help restore muscles that often stiffen or spasm due to back injury. A combination of pain and inflammation relief with physical therapy and massage or other soft tissue relief is ideal for returning the sciatica sufferer to normal daily activities and restoring range of motion.

While each physical therapy program is tailored to the individual patient, they often have many elements in common. People with back problems often have weakened abdominal muscles and tight back muscles. The hamstrings are also often tight in sciatica patients, so both massage or TENS treatment as well as stretching can be used. Strengthening the back and abdomen helps to support the spine and keep it in proper alignment. Weight training is often combined with stretching, Pilates, and low or no impact exercise to rehabilitate the body gently while medication controls the pain and inflammation. Ideally this treatment can postpone or prevent the need for surgery. Often this kind of conservative treatment brings the patient a good deal of relief from his or her symptoms and surgery is not necessary.

If the patient does need surgery, a minimally invasive approach combined with the above rehabilitative treatment can effectively treat the pain of sciatica. Depending on the cause of sciatica, a surgical patient often needs either a microdiscectomy or discectomy, or a laminectomy or laminotomy. All of these procedures can be performed using minimally invasive techniques, which allow for less anesthesia, little to no hospital stay, and a much faster healing time than traditional open surgery. Minimally invasive procedures do much less damage to the soft tissue surrounding the damaged disc or discs causing the symptoms, so physical therapy can begin soon after the surgery, which greatly increases a positive outcome.

June 11, 2014

When a patient undergoes endoscopic spinal fusion surgery, he or she must stay in the hospital for at least two days after surgery. The first day, someone from the hospital’s physical therapy staff (PT) will come to get the patient up and walking. It will be determined whether the patient needs a walker. Walking may be painful at first, especially if a bone graft was taken from the hip for the fusion surgery. PT will also show the patient how to perform basic daily tasks, such as getting out of bed, and discuss how to avoid putting stress on the spine after surgery.

On the second day, PT makes sure that the patient is walking independently and makes sure that he or she will be able to function at home. In order for the patient to be discharged, it is important that the patient be able to walk, go up and down stairs, and get in and out of bed independently. Some patients need a cane or walker for a couple weeks after surgery. This will be determined before the patient leaves the hospital.

Patients who have had endoscopic spinal fusion surgery, rather than traditional open spinal fusion surgery, can usually go home on the second day after surgery. Sometimes older or more frail patients have trouble walking or functioning independently after surgery and need extra rehabilitation. Usually the spine surgeon will be able to tell the patient ahead of time if he or she should expect extra rehabilitation after endoscopic spinal fusion surgery. After the surgery, the patient’s doctor, physical therapist, and occupational therapist will work together to determine whether the patient needs extra rehabilitation. Extra rehab can be done either at the patient’s home or at an inpatient rehab facility.

What Causes A Back Spasm?

by Carl Spivak

A back spasm is a sudden, painful muscle contraction in that back near the spine. It often occurs while lifting, pushing, or pulling a heavy object or performing some other action that would strain the back. The patient’s pain often increases within the next two or three hours after the injury, and any movement of the back usually causes severe pain. Sitting, standing and bending usually cause the patient great pain, and for many lying on one side in a fetal position offers the only relief from pain.

Spasms are more likely to occur if the muscle is already swollen or strained. If force is added, previously damaged muscles and tendons can tear. Any sport or job that requires twisting, pushing or pulling can cause a back spasm. Those with a weakened back from conditions like spondylolysis, spondylolisthesis, disc rupture, spinal stenosis, arthritis, are more likely to have back spasms. Similarly those with anterior pelvic tilt, tight hamstrings, weak muscles along the spine or in the abdomen are also more likely to suffer from back spasms.

The patient should rest as much as possible and treat the site of the injury with ice and compression. Muscle relaxants and anti-inflammatory medication and sometimes even local anesthetic injections can be used to treat the injury during first few days after the injury. Four or five days after injury, these treatments can be supplemented with massage or chiropractic care. As the severe pain of the injury begins to clear, the cause of the injury should be determined by the physician so that further treatment, such as strength training, physical therapy, or even in rare cases surgery, can be considered, depending on the reason behind the muscle spasm.

As people age the spine starts to wear out. The spine undergoes wear and tear from daily living, work, sports and accidents. This damage weakens the discs and facet joints, producing instability or abnormal movements of the spine. If this process continues, the spine may fall apart and one vertebra may slip forward relative to another vertebrae. This process is called spondylolithesis. Instability puts stress on the discs, ligaments, tendons and bones, which stimulates new bone formation to strengthen the spine and hold it together. This new bone formation is called bone spurs or osteophytes.

Bone spurs may pinch nerves inside the spinal canal. The spinal canal may be compressed in the center, outer gutters, exiting hole or just outside of the spine. Central compression is called central spinal stenosis. Gutter compression is referred to as lateral recess stenosis. If the nerve is compressed in the foramen or hole exiting between the vertebrae this is called foraminal stenosis. Lastly, if the nerve is compressed outside of the spine it is called far lateral stenosis. This may cause neck, arm, back and leg pain depending on the location of the bone spur. The pain may be associated with numbness, tingling and weakness.

Bone spurs may be seen on X-rays, CT and MRI. X-rays show irregular white areas in the spine. CT scan shows the size, shape and location of bone spurs best. MRI scan is good at showing if the bone spurs are pinching the nerves. EMG (electromyography) nerve studies can help confirm nerve irritation and injury.

Spinal injections may be used to determine if the bone spur is causing pain. This is called pain mapping. A spinal needle is placed where the bone spur is pinching the nerve under x-ray guidance. Numbing medicine is injected on the bone spur and nerve. If the bone spur is the cause of the pain, the pain will temporarily improve or stop.

Patients who do not benefit from conservative treatment may benefit from surgical treatment. Traditional surgery involved removal of the facet joint to take pressure off the nerve combined with spinal fusion and instrumentation to hold the spine together. Today back and leg pain may be treated with endoscopic foraminotomy.

Endoscopic foraminotomy a micro video camera is inserted through a very small incision onto the bone spur pinching the nerve. The camera projects the images onto a video screen so the surgeon can easily visualize the compression. Tiny instruments are inserted through the camera to decompress the nerve relieving pain and suffering. Advantages of endoscopic spine surgery include twilight sedation (usually avoid general anesthesia), very small incision (size of a finger nail), minimal postoperative pain and much shorter recovery then traditional fusion surgery.

The spine is made up of many bones called vertebrae. The front of each vertebrae is made up of a square shaped vertebral body, disc, and ligaments. The discs act to cushion the vertebrae, but if the vertebral body weakens or is injured by excessive force, it may break and flatten like a pancake, which can cause terrible back pain. Osteoporosis, the condition of having weak thin bones, is the primary cause of vertebral body compression fractures; less common causes include severe trauma, infection or cancer.

Pain is the most common symptom of spine fractures. Even the smallest movement of the patient’s body causes micro-motion in the broken bone, which produces severe pain. The patient’s pain level usually decreases when she is lying down and increases with standing, walking and lifting. Sometimes people have no pain at all. Rarely fractures may cause numbness, weakness, paralysis or bowel and bladder dysfunction from spinal cord or nerve compression. Fortunately, this severe back pain often improves during the first month after injury.

X-ray, CT, bone scan and MRI may diagnose spinal fractures. Besides diagnosing the fracture, MRI scans can determine if the fracture is new, judge its response to treatment, and rule out nerve or spinal cord compression.

How are Osteoporotic Spine Fractures Treated?

Patients who don’t see significant improvement with conservative treatment may benefit from surgical treatment. The key to surgical treatment is stabilizing the fracture. The spine, like a broken arm, must be “cast” to stop abnormal bone movement to prevent pain. Surgical options include vertebroplasty, kyphoplasty and major spine surgery. Major spine surgery is not commonly needed to treat osteoporotic compression fractures.

Vertebroplasty and kyphoplasty are the most common treatments for osteoporotic compression fractures. These procedures involve the placement of a needle into the fractured vertebral body for the injection of liquid cement. Once the liquid cement hardens it stabilizes the vertebral body decreasing painful movements. If there is concern for cancer, then a bone biopsy is sent to pathology for examination.

Vertebroplasty is an outpatient procedure, done under conscious sedation like a colonoscopy, but can be done under local anesthesia in high-risk patients. A needle is placed into the fractured vertebral body under x-ray guidance and then liquid plastic is slowly injected to harden and stabilize the fracture.

Kyphoplasty is similar to vertebroplasty, but kyphoplasty involves the placement of two needles on each side of the spine and balloons into the broken vertebra under x-ray. The balloons are slowly inflated to expand the collapsed “pancake” vertebral body and create cavities to hold the plastic. Plastic is then injected after the balloons are removed to support and stabilize the broken vertebrae.

Some patients report immediate pain relief. The remaining patients generally experience pain relief or a lessening of pain within the next two days. Patients can return to daily life the day after surgery, though they should avoid heavy lifting for at least the first six weeks. Each patient should take their surgeon’s advice about returning to activities, as each patient is different. All patients, but especially women, should speak to their doctor about treating their osteoporosis and preventing further bone loss. Women who develop vertebral body compression fractures are at least 4 times higher risk of developing future spine fractures. Elderly patients with bone fractures should undergo investigation and treatment for osteoporosis.

Due to the many advantages of endoscopic spine surgery, it should always at least be considered, but currently it is not a replacement for all types of spine surgeries. Fortunately, with the advancement of surgical techniques and equipment, it is being used to treat a wider scope of injuries.

Why might endoscopic surgery be an option when other types of spine surgery are not?
Traditional surgery is limited because the surgeon must see the problem directly, whether with their eyes or a microscope. The endoscopic camera visualizes areas that are not usually visually accessible through holes into the side of the spine and around corners. This greater visualization combined with minimal damage and lowered surgical risk increases the spectrum of pathology that can be treated safely. This allows endoscopic surgeons to treat spinal disorders that traditional surgery may not treat. This happened many years ago in orthopedic surgery, when the endoscope was introduced to knee surgery. Today no one doubts the incredible benefits of endoscopy of the knee, and we are quickly seeing this happen in spine surgery.

Can endoscopic spine surgery help everyone?
Sadly, not everyone can be helped by endoscopic spine surgery. It is still spine surgery, which has inherent risk that is off-putting to some patients. Other conditions simply cannot yet be treated by this technique. Endoscopic spine surgery is the next advance in the treatment of spinal disorders, but it is not a cure-all.

Why isn’t all spine surgery done this way?
These procedures require a unique combination of skills that take time to acquire. There are only a few surgeons who have focused on mastering these advanced techniques. Endoscopic spine surgery is a hybrid procedure that falls in between interventional pain and minimally invasive spine surgery. It is a relatively new, cutting-edge technique. Endoscopic spine surgery is the future.

What are the advantages to endoscopic spine surgery?
▪ No general anesthesia
▪ Very small incisions
▪ Minimal damage to skin, muscle, ligaments and bone
▪ Minimal blood loss
▪ Less post-operative pain
▪ Faster recovery

What is Facet Arthropathy?

The spine is made up of bones, discs and facet joints. The discs and facet joints allow the spine to flex, extend, turn and bend to the sides. The discs are located in the front of the spine; they support and allow movement between the vertebral bodies. The facet joints are located in the rear of the spine, one to two inches off the midline on the right and left sides. Facet joints are synovial joints lined with cartilage and filled with fluid. Each joint is held together by a thick capsule. These small joints allow the facet bones to slide back and forth with minimal resistance.

Unfortunately over time the facet joints break down from aging, wear and tear, injury, instability, and slippage of the spine. The gradual wear of the facet joints is called degeneration. These degenerative changes of the facet joints can produce severe debilitating pain.

Facet arthropathy is often called as arthritis of the facet joint. The most common cause of facet arthritis is osteoarthritis. Osteoarthritis causes breakdown and swelling in the cartilage of the facet joint, ultimately producing bone on bone rubbing or grinding. The body tries to stop this rubbing by thickening the joint, creating arthritis. This type of arthritis may produce pain and stiffness which worsens with the extension of the neck or back. If the joints enlarge too much, they can pinch nerves causing arm or leg pain or numbness.

Facet arthritis in the neck causes neck and shoulder pain, in the midback it causes midback pain and in the lower back it causes lower back, buttock, upper leg, and occasionally lower leg pain. Pain usually increases with extending (bending back) or twisting the neck or back, and the affected joints may be very tender to deep pressure on examination.

How is Facet Arthropathy Diagnosed?

Facet arthropathy may be diagnosed on X-rays, CT and MRI scans. CT scans may show thickened and irregular facet joints. MRI scans may show fluid in the joints (joint swelling), thickened ligaments and bones, as well as pinched nerves. These imaging studies only show the physical abnormality. They do not indicate if these changes are responsible for your pain.

To determine which structure is causing the pain, the patient may undergo pain mapping. Injections are used to locate where the pain is coming from. Numbing medicine is injected into the facet joint or onto the facet nerve (medial branch nerve). If the facet joint is the cause of the pain, the pain will stop or decrease. If the pain does not improve, then it is originating from other structures, such as the bones, discs, ligaments, spinal nerves, etc.

How is Facet Arthropathy Treated?

Patients who have not been helped by conservative treatment may benefit from surgical intervention. Traditionally these patients had been treated with either a large open fusion surgery of the discs and facet joints or facet joint injections and radiofrequency ablation. Radiofrequency ablation is an interventional pain procedure where electrodes are placed onto the facet joints to burn the nerves transmitting pain from the damaged facet joints. The burning electrodes are placed onto the spine under X-ray guidance. The nerves usually recover from the injury after six months or so and the pain returns. Fortunately radiofrequency ablation can be repeated.

Are There Minimally Invasive Treatments for Facet Arthropathy?

Facet joint pain can be treated with the spinal endoscope. Endoscopic rhizotomy treats pain that originates from the facet joints and medial branch nerves. A high definition endoscopic video camera the size of a pen is inserted through a tiny incision into the painful facet joints. The facet joints are cleaned of the painful tissue and the medial branch nerves are found and cut under direct visualization through the endoscope. This is like a “root canal” for the spine. Patients usually have almost immediate pain relief and quick recovery. Endoscopic rhizotomy may produce pain relief for years, unlike radiofrequency ablation which must be repeated every six months or so.

Severe facet pain that is not responsive to endoscopic rhizotomy may be treated by endoscopic fusion. Endoscopic rhizotomy blocks the majority of pain transmission from the joints, but not all. This prevents the patient from accidentally injuring himself. If the spine is unstable and puts extensive stress on the facet joints, or if there is significant pain originating from the disc or other structures, the spine may still need to be fused. Fortunately there has been much advancement in fusion technology and it can now be accomplished using minimally invasive surgery. This procedure is performed through a one inch incision with the help of endoscope or microscope.

Endoscopic fusion treats degenerative spinal disease and instability which can cause back and leg pain. The damaged disc is removed through the endoscope and spinal endplates are prepared for fusion under direct visualization. Endoscopic fusion is done under general anesthetic, facilitating the insertion of spinal instrumentation. Patients are usually discharged the same day after surgery, and have much less pain and a quicker recovery compared to traditional fusion surgery.

The Most Common Question About Minimally Invasive Spine Surgery

April 14, 2014

Why is endoscopic spine surgery better than traditional surgery? Traditional surgery is more destructive in its approach to the spine, and often creates new damage while treating the problem. The larger the incision, the more damage to muscle, ligaments, and bone. This greatly increases the potential for muscle weakness. This collateral tissue damage may result […]

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