Cancer Of The Spine Symptoms

my name is faheem sandhu,i'm director of spine surgery in the department of neurosurgery atmedstar georgetown university hospital. i specialize in the treatment of minimallyinvasive approaches to spinal disorders that affect all parts of the spineand spinal chord from the neck, the middle of the backand lower back. this basically involves makingsmaller incisions, splitting through the normal musculatureso we preserve as much of the normal anatomy and structures,but still achieve all of the goals of surgery in terms ofdecompressing the spinal chord or nerves

and stabilizing the spine if we needto do a fusion procedure. i would say 85% of what i do surgicallyis amenable to minimally invasive techniques. at medstar gerogetown we havea number of tools that allow us to treat both complex and straightforwardspine problems and i think you need that breathof techniques to really cover the full gamut of spinal problems. i really love my job, i think it'sgratifying to help people who are in pain or have disabilityand allow them to be pain-free

and recover from theirweakness and disabilities, and to me it's a very exciting field,it's evolving, we're doing new techniques that allow usto treat problems that we haven't been able to treat as effectivelyin the past, and i'm constantly rewardedby seeing my patients do well and that certainly keeps me motivated.i think what we offer at georgetown is the ability to treat the maximum numberof problems that affect the spine in using minimally invasive techniques because we're familiar with all of thetechniques and how and when to use them.

i think, done for the right reasonsand done with the right techniques, people can have excellent outcomesfrom surgical intervention it can be life-altering, to take someonewho was not walking to being pain-free and walking and reallyreturning to a normal quality of life. we differ in our background in termsof training and orthopedists work generally with bones or in the bodyand throughout the body, including the spine. neurosurgeons dealwith the brain, spinal chord and all the nerves, and so there's anoverlap between those two specialties when it comes to working on the spineand historically,

the orthopedic surgeons would do a lotof the bone work or deformity correction and neurosurgeons would work closerto the spinal chord or nerves and often time we shared thoseresponsibilities and surgeries and did them together. however,i would say in more recent times, those boundaries have blurred and nowthere's almost a common specialty of spine treatment, and i think a goodorthopedist or a good neurosurgeon specializing in the treatment of spinaldisorders do very similar work. back pain is one of the most commonailments that effect people, and either... you know,one of the most...

number 2 on the list, i believe, of reasonspeople seek medical attention, but the majority of these people,probably greater than 90%, don't need any significant interventionbut, you know, people who have persistent painthat just doesn't go away, with normal over-the-counter medicationsor short course of physical therapy, they probably need to be seen by a specialistand certainly if they have any pain which radiates into their arm or leg,that suggests compression of a nerve and warrants a little bit more attention. it is a different approach to treatingcommon disorders of the spine

and it involves basically preservingtissues by splitting through muscle instead of making big incisions andstripping the muscle off of the bone, which usually devitalizes the muscleespecially in the lumbar spine and effects the function long-termand also may effect the need for additional surgeries long-term. so with minimally invasive procedureswe're able to make smaller incisions, focus on the area of the problemor pathology in the spine and we split through the muscles,so when i take out my retractors, the muscle comes back togetherand functions better

and the recovery is faster,blood loss is less. most common spine problemscan be treated using minimally invasive techniques,so starting with problems in the neck, disc herniations can be treatedusing minimally invasive procedures coming either from the back of the neck,making a small incision, splitting through the musclesand decompressing the nerves, even removing small disc fragments that way,certainly in the thoracic spine we can treat disc herniationsin a similar way, even tumors have been treated usingminimally invasive techniques

of the spinal chord or the spine,and in the lumbar spine i think we've seen the most significantadvances and that's the most common area where we dominimally invasive procedures and that involves doing simplesurgeries like disc herniations or treating stenosis or compressionof the nerves, either at one or multiple levelsthrough small incisions which allows me to do surgeryon much older patients. so people even intheir late 80's or 90's, i've operated on people in that age range,are eligible for surgery,

whereas with a bigger surgery,bigger blood loss, more recovery, they're really not good candidatesfor surgery. but using minimally invasive techniquesit really opens up a spectrum of opportunities for patients that maynot otherwise have been considered surgical candidates. and now we'realso doing all the common spinal fusions using less invasivetechniques, muscle splitting, and that includes placing pedicle screwsand doing fusions one or two levels all withminimally invasive techniques. no, and it really requires specializedtraining either during fellowship

or extended courses to really learn and then masterthese techniques, but... you know, someone who's made thecommitment to do that, certainly would be capable ofdoing that with either a neurosurgicalor orthopedic background. i do not use a laser inany of our techniques of minimally invasive procedures. laser had been used a number of years agofor some forms of discectomy. those types of discectomies actuallywere shown to be less effective

in long-term outcomes, and most peoplehave gotten away from using any laser for these common procedures. the keyto minimally invasive approaches is not the use of a laser or marketingthe use of a laser, it's really preserving the anatomy,splitting through the muscles and then accomplishing the samesurgical goal that you would do in an open manner. we're justgetting to the spine in a much less disruptive manner. so one of the newer techniquesthat i've been utilizing in treating lumbar stenosis or compressionof the nerves is a technique of

introducing a shaver under the facet jointwhich will allow us to decompress the nerves not onlyin the spinal canal but the ones that are comingout of the spinal canal. and traditionally, a lot of these people,because of the bad compression of the nerves in both areas,we would totally decompress the spine, remove those joints, and that wouldnecessitate doing a fusion afterwards because you've taken away so much bonethat the spine is no longer stable. with this device, it's called io-flexmade by a company named baxano, you introduce a wire that goesunder the joint,

you confirm that it's in a safe placeabove the nerve using monitoring, and then we, basically just like a nail-file,shave the under-surface of that joint and that creates a lot more spacefor the nerve. i think i've avoided doing some fusionsin that manner, and patients have done very wellin terms of resolution of their back and leg painfollowing this procedure. it's a way of getting to an areathat is very difficult to get to surgically without removing all of that joint,and it's really the under-surface that you have to clean outand the instruments,

the traditional instruments that wehave are not very effective in reaching out underneath the boneand the joint to properly decompress the nerves,but this technique really allows us to do that and still preservethe joint and its function. older patients with back painradiating down the leg, they failed treatment with physical therapy,with injections, and now they need surgery, and they haveon their x-rays and mri scans clear evidence of compression of thenerves not only in the spinal canal, but in the outlets of the spine,where the nerves come out of the spine

and i think they're the ones thatare best suited for this treatment, and then even some people withwhat's called spondylolisthesis or a slippage of the vertebrae, and that's not an uncommon problemto see as people age. you get a little bit of slippageas the spine degenerates. sometimes that's associated with clearinstability, where the spine... those vertebrae move, and in those caseswe recommend doing a fusion in addition to thedecompression procedure. but many of those people, they have theslippage but it's stable and it doesn't move.

but when the bones slip like that, itnarrows the outlet spaces for the nerves and getting the shaver underneathallows us to open up those spaces without needing to fuse the spinebecause there is no clear instability there and by also preserving the normal musclesand ligaments, we're not destabilizing the spinefurther so i think a lot of these people do very welllong-term because we're preserving all of those structures and we're notcreating instability, we're just decompressing the nerves,treating the underlying problem and they get improvement in boththeir back and leg pain.

spinal fusion is a surgical treatmentwhere we join two vertebrae together or more than two vertebrae togetherand long-term it's bone that heals and joinsthose together and temporarily we use screwsand rods to link them together while the bone heals. and most peoplethat require spinal fusions have some degree of deformity,like scoliosis, curvature in the spine, or instability where two vertebrae aremoving relative to another and sometimes people who have tumorsor trauma also require spinal fusions to stabilize their spine if there'sinstability or fracture.

those are probablythe most common reasons. certainly minimally invasive techniquesare used to achieve spinal fusions as well. i've been doing single-level fusionsusing a minimally invasive technique called a transforaminal inner-body fusion and we place pedicle screwsas well as cages in the disc space and that can be done througha 2.5cm incision. another technique that we useis coming in from the patient's side, it's a lateral inner-body fusionwhere we clean out the discs and go through the psoas musclewhich sits on the side of the spine

and that's a very useful techniquefor treating patients with deformity or even slippage of the spine,and then certainly in the thoracic spine we can perform fusions by placing pediclescrews in a minimally invasive way with guide-wires and needlesthrough small incisions and that's been very beneficialto some of our patients. in my experience, most people recoverfaster from minimally invasive surgeries because we're just splitting throughthe muscles and so generally the hospital stays are shorter,they average 2-3 days versus 4-5 days with thetraditional techniques.

after a single level of spinal fusionthere's no reason to expect that you couldn't do everythingyou wanted to do, even if you wanted to continue athletics and many of the normal activitiesthat you enjoy, i think once the bones have healedand you've recovered maximally all of those things are possible. the majority of our techniques stillrequire general anesthesia. but the risk of needing blood transfusions,the amount of blood-loss, the length of the surgeries is certainlydecreased with some of these procedures

and i think that's been clearly demonstratedin multiple studies and multiple institutions that theseprocedures definitely reduce blood-loss, need for transfusion, length of hospital stayand the need for narcotic pain medicines after surgery. the pain from a typicalminimally invasive discectomy, where we make a very small,less than 1 inch incision and split through the muscles and workthrough a tubular retractor, that can be pretty minimal for some people,and i've had patients who've stopped taking pain medicine within 3 daysof their surgery.

yes, i think the nice thing about usingthese techniques is that it allows us to be less disruptiveand the majority of my patients who i perform discectomies, alsodecompressions for lumbar stenosis and sometimes decompressions in the neckfrom the back, all can go home the same dayand many of those people are off the narcotic pain medicineswithin a week of surgery. you may need to wear a brace afteryour spine surgery if you've had a multi-level fusion that expands manylevels in the spine, generally for one or two levels of fusionin the spine i think it's unnecessary

to wear a brace, and the screwsand the rods that we place serve as an internal braceand are adequate. one of the more dramatic areas thati've seen minimally invasive surgery affect my patients is certainly that peoplethat were just considered not surgical candidates at all becausethey have a lot of other medical problems or just too sick or they're too oldand people just considered it high-risk to do a surgery wherethere'd be a lot of blood-loss, a long term recovery and probablynot a meaningful outcome. but using these less invasive techniquesyou can really achieve those goals

in a very reasonable manner for thesepeople and allow them to enjoy a much higher quality of life. it really depends on the underlying problem.certainly some of the more complex deformity surgeries were still evolving,what's the best approach in terms of usingminimally invasive techniques and i certainly have used them for someproblems like degenerative scoliosis in older people, but we want to achievethe best outcome and if that's at all... if i feelit's going to be a compromise by using a minimally invasive approach,then i will elect not to do that.

or sometimes we can combine one techniquewith an open technique and still decrease blood-loss or improvecertain aspects of that surgery by combining the techniques. even in the spine community there arethoughts that... especially with the minimally invasivespinal fusions that the fusion rate would not be as goodor the outcomes would not be as good, and i thinkthat has not held out. i mean, certainly... if one ismeticulous and pays attention to all the necessary details while they'redoing the surgery,

fusion rates are quite high and in mypractice that has not been an issue at all, and certainly in our literature thathas not held true either. so i think some of the concerns,even in the surgical community about the down-sides of minimallyinvasive surgery have not borne out. well, i think the key to a healthy backis always prevention and i think the things we havein our control are probably 3 things: 1 is, i'd say, do not smokeand if you do, you should stop because cigarettes damage not onlythe lungs and your blood vessels, but your discs and your spine and createdegenerative changes

and accelerate those, so that's number 1.number 2 is: maintain your weight so you don't get over-weightand stay fit, and regular exercise to keep yourcore muscles strong, your back and abdominal muscles,and i think those are the 3 things that we have in our control.you can't control your genetics or sometimes your environment,but i think... you know, a little bit of preventiongoes a long way, so ... certainly i think it would be worthreconsidering what could be done for your spinal condition becausethe techniques have evolved

certainly over that time periodand it may be that there are newer techniques that wouldsolve the underlying problem better. well, i spent a year learning thesetechniques with one of the gurus who helped pioneer the fieldin chicago and during that time we were reallyhelping develop these techniques, i really felt like i was in kind ofthe epicenter of a new field being started and it was very exciting.still to me, it's very exciting to be part of an evolving field.