Orthopedic Advances

NewYork-Presbyterian

Advances in Orthopedics

Taking Spine Surgery to New Heights

The NewYork-Presbyterian Och Spine program provides the highest level of expertise; clearly defined preoperative, intraoperative, and postoperative protocols for preventing infections and neurological complications; and a dedicated team of surgical, medical, radiologic, and rehabilitative spine specialists.

At NewYork-Presbyterian Hospital, neurosurgeons and orthopedic surgeons are providing highly specialized expertise to treat all levels of spine complexity, changing the lives of patients from around the world who seek out their care. Their specialties range from endoscopic procedures to the most complex spine reconstruction surgeries. Dedicated spine teams work in collaboration with our spine specialists to incorporate stringent safety practices that continue to optimize outcomes, including preoperative protocols to lower risk for complications and postoperative guidelines to promote mobilization and manage medications.

The Endoscopic Procedure

Minimizing tissue injury, trauma, and postoperative pain is critical to maximize a patient’s recovery from spine surgery. Faculty in the Department of Neurosurgery at Weill Cornell Medicine are applying the latest techniques and technologies now available in minimally invasive spine surgery.

Today, indications for the less invasive endoscopic spinal approaches are expanding, particularly in the lumbar region. In some instances, Weill Cornell neurosurgeons can perform an endoscopic procedure as opposed to doing a fusion, a much larger operation. With exquisite precision, they are able to perform spinal decompressions and discectomies through 7mm incisions. They operate via tissue and muscle-sparing corridors from natural openings into the spinal canal. Micro instruments enable them to remove herniated disks and bone spurs in a minimally invasive approach as well.

Taking a Circumferential Approach

Weill Cornell spine surgeons often take a circumferential approach to the spine, pushing the envelope of performing extended applications for complex pathologies through smaller corridors. Using an anterior approach, they can access the retroperitoneal space through an abdominal incision, or use a thoracic approach into the lateral corridor, going through the flank or between the ribs, and then performing percutaneous posterior instrumentation. Circumferential approaches generally involve multiple small incisions versus one extended incision in the back and this often translates into less global tissue disruption.

Collaborations Maximize Expertise

Some approaches call on established collaborations with other surgical specialists. For extended anterior approaches to the cervical spine, for example, Weill Cornell neurosurgeons collaborate with a Weill Cornell ENT partner. Their skills in this region help to facilitate access in cases that may address complex deformity, tumors, or revisions and that require larger openings with more tissue mobilization.

For anterior retroperitoneal lumbar approaches, they enlist the assistance of a Weill Cornell vascular surgeon, who can mobilize the aorta or vena cava to provide access to the front of the spine, allowing the neurosurgeon to continue the surgery once the narrow corridor is established.

Innovative Surgical Solutions

Transforaminal endoscopic lumbar approaches involve working in Kambin’s triangle and are performed on awake patients or under general anesthesia with continuous electromyography. The potential for morbidity in this approach includes injury to exiting and traversing nerve roots as substantial dissection or cauterization of overlying tissues is required for visualization. Weill Cornell neurosurgeons have developed a novel connection system and technique that accepts input from a bipolar radiofrequency probe to allow for accurate identification of the exiting and traversing nerve roots with minimal changes to the workflow of transforaminal endoscopic lumbar approaches. In a recent study of the radiofrequency device connection published in the May 2020 issue of World Neurosurgery, the researchers reported on 30 patients undergoing transforaminal endoscopic lumbar approaches for discectomies, foraminal stenosis, or lateral recess stenosis. None developed injury or pain related to nerve root dysfunction.

Vertebral Column Resection

Vertebral column resection (VCR) is a safe but challenging technique reserved for the most severe primary or revision spine deformity cases. The procedure involves removing one or several vertebrae, separating the spinal column into two pieces, and then realigning the spine to make it straighter without overstretching the spinal cord. It is one of the most difficult procedures to perform, and only a handful of surgeons around the world are equipped to offer the approach. The experience and skill set to perform VCR is found in the Department of Orthopedic Surgery at Columbia University Irving Medical Center. Here, orthopedic surgeons use an all-posterior VCR approach. This single stage, posterior-only approach offers dramatic radiographic and clinical correction of severe deformities and obviates the need for the traditional circumferential approach with anterior releases via discectomies, followed by posterior instrumentation and fusion.

To minimize neurological risks and spinal cord-related wound, instrumentation, and fusion complications, the Columbia spine team incorporates several practices, including the following:

3D Models

For the most complex spinal deformity surgeries, our surgeons employ CT imaging data to create three-dimensional models for preoperative guidance in order to precisely plan the placement of screws and other aligning techniques before and during surgery. Studies have demonstrated that 3D printing guides are associated with increased screw accuracy and favorable deformity correction outcomes.

Monitoring and Mapping

Multimodal intraoperative use of spinal cord monitoring, in particular, transcranial motor evoked potentials, is imperative for VCR surgery to prevent neurologic complications. Columbia spine surgeons combine monitoring with dynamic spinal cord mapping in which a flexible epidural catheter is placed at different spinal levels to dynamically stimulate the spinal cord and map out the site of data loss corresponding to the area of neural compromise. These tools enable early detection and identification of the site of neurophysiologic data loss, permitting focused attention to the site of compromise to reverse the cause, improve the chance for return of baseline data, and prevent the potential for permanent neurologic damage.

In addition, our spine surgeons have developed a novel MRI-based classification of spinal cord shape and the presence of compression fractures at the curve apex to assess risk of intraoperative neuromonitoring data loss during thoracic spinal deformity correction. In a study recently published in the August 8, 2020, issue of Spine Deformity, Columbia faculty report on this simple classification system. A review of 81 Type 1, 32 Type 2, and 12 Type 3 spinal cord cases, lower extremity transcranial motor-evoked potentials and/or somatosensory-evoked potentials were lost intraoperatively in 21 cases, with full recovery of data in 20 of those cases. Their analysis showed that Type 1 cords were protective against intraoperative data loss; Type 2 cords had no association with data loss; and Type 3 cords had significantly higher odds of intraoperative data loss. The data provided the foundation for the new spinal cord risk classification scheme to identify patients at increased risk for loss of spinal cord monitoring data.

An Interprofessional Enterprise

VCR and other demanding vertebral osteotomies require extensive pre, intra, and postoperative management of the patient. At Columbia, patient care is highly coordinated with hospitalists, intensivists, cardiologists, endocrinologists, pulmonologists, and other specialists to optimize surgical outcomes and facilitate recovery.