Superior Surgery

Often in the hazy world of Internet postings and braggadocios marketing, it is difficult for the patient unfamiliar with spine surgery or surgery in general to discern what is good and truly superior surgery. However, there are certain specific OR techniques and general principals, which one can follow to increase the likelihood of a good outcome and patient safety.

Going the Extra Mile for Excellence
Outcomes
The Diagnosis
The Surgeon

**Note to Lumbar Patients: Prof. Dr. Bertagnoli uses the retroperitoneal approach to the spine in ADR surgery and does not recommend the transperitoneal approach. While the transperitoneal approach is much faster and we knew of at least one surgeon who used it, the risk of infection and other complications are unacceptable. This surgeon has now changed his technique, but does not use an adhesion barrier, claiming it is not necessary, because he now uses the retroperitoneal approach. This is not good news to his patients, who may need anterior spine surgery in the future, as another ventral approach to the spine without a previous adhesion barrier is quite risky for exsanguination.

GOING THE EXTRA MILE FOR EXCELLENCE:

What does this mean in practical terms? Prof. Dr. Bertagnoli’s willingness to go the extra mile for excellence can be seen in many ways. For example,:

In ADR surgery, surprisingly many well-known, aggressively-marketed hospitals and surgeons do not use a fluoroscope to place the ADR in the vertebrae on the AP midline (coronal view) or to judge the sagittal placement of the ADR, fore and aft. (Lack of use of the fluoroscope also occurs in fusion surgery). Of course, Prof. Dr. Bertagnoli does use a fluoroscope. Placement is absolutely critical to the success of the operation. There is normally only a 1.5 mm tolerance in a single level surgery on each side of the vertebrae, depending on the device, sometimes less. Tolerance levels for placement error go down radically in multilevel surgery. Unfortunately, the patients of these surgeons often require revisions, because bio-mechanical stresses can cause facet problems and constant back muscle adaptation from constant compensation for the resulting imbalance of the spine. Prof. Dr. Bertagnoli will do revisions on these patients. Unfortunately for the patient in the image we have an example of a misaligned and misplaced ADR stressing the entire spine. Fortunately a dorsal stabilization can be done to correct the situation.


In the next example we see the same problem of coronal imbalance developed from misplaced cervical implants. Initially patients may feel no or little pain with this misalignment. However, it is very likely that the stresses put on the muscles will eventually lead to pain and facet problems. In this image we can see the beginning of the misalignment of the spine. The facets are more likely to occur when anterior and posterior misalignment occurs.

In the next example we see a misplaced fusion screw, which severely damaged the disc below it. Fortunately, in this case Prof. Dr. Bertagnoli was able to repair and remodel the damage vertebra and place an ADR below it.

The key-way for ADR should never be chiseled in the cervical spine. This represents a severe risk to the patient's safety and there has been reported at least one very serious accident using this technique. The key-way should always be drilled or sawed for precise control in the cervical spine. Of course, Prof. Dr. Bertagnoli uses a drill in the cervical spine for the key-way of the ADR. Then the ADR is gently tapped in.

Here we see a hybrid construct, that is a fusion in combination with ADR. These segments require significant engineering to prevent the pseudolisthetic, a (“slipped”) position, also called a subluxation. This subluxation will stress facet joints. It will also narrow the neuraforamina of that level to impinge the nerves that should have been liberated during the surgery. This patient remains in pain and is considering revision with Prof. Dr. Bertagnoli.


Proper sizing of the ADR is critical for success. The ADR is sized on the height, width and angle of the normal position of that level of the spine. Most errors that we see come from inadequate width of the ADR. The plates of the ADR should nearly cover the endplate of the vertebral body. This helps to prevent subsidence and autofusion. The autofusion is a result of osteophytes growing around the ends of the ADR. The image on the right shows autofusion, where osteophytes have grown around the ADR and now the patient's neck is frozen. This was done by a well-known and aggressively-marketed hospital. Prof. Dr. Bertagnoli will perform revision on these cases. This patient is now doing well after an eight hour revision surgery.

Careful removal of debris is an indication of good surgical technique. Too often we see the debris from previous surgeries causing complications. Surgery is not a race, where the doctor, who finishes first wins. The surgeon must remove all material from the discectomy and vertebrae remodeling. In the poor but instructive MRI on the right we see debris from a previous surgery impinging on the spinal canal. Again this was performed at a well-known and aggressively marketed hospital.

  • In ADR surgery, he spends more than the standard OR time in remodeling of deformed and diseased vertebrae. This is tedious work but it must be done to ensure no osteophytes are left to compress the nerves and in some cases the angulatures of bone endplates are correct.

    The importance of applying bone wax to remodeled or ADR preparation sites cannot be over emphasized. The bones see these areas as damaged and will grow osteophytes in these areas to protect themselves. Application of bone wax to ADR preparation sites in the bone or remodeled areas of the bone helps prevent osteophytes from growing.

    Prof. Dr. Bertagnoli preserves the anterior longitudinal ligament between the vertebrae whenever possible. He does this by cutting a window in the ligament and placing the ADR through the window. When complete he sews the window shut. The ligament heals and is preserved. Some surgeons this ligament is not relevant and take no measures to preserve it.

    Dexa bone scans help in the judgment in the quality of bone. All ADR surgeons should use this procedure, many do not. Some only use it when there are indications, such as the sex and age of the patients. (Indeed, Prof. Dr. Bertagnoli has discovered that men have lower bone densities than expected) Although there is approximately a 20% error (that is 20 % chance of a false positive and false negative), it is a good indicator of bone strength. Prof. Dr. Bertagnoli also makes perioperative judgments about bone quality during surgery. Weak bones can be made ready for ADR surgery with AMP vertebroplasty, which is an injection of bone cement into the bones. AMP vertebroplasty must be done with great care, it is not without risk.

    Many ADRs have keels. These ADRs require drilling or sawing of the keyway for the keel. Drilling is the safest method. This keyway must be checked for debris before the ADR is tapped in. It cannot be assumed to be clear. Checking the keyway should be part of any ADR surgeons procedure. Serious injury can happen and has happened patients, where this has not been done.

    In ADR surgery, he has the patients wear an (soft) orthesis after surgery, because he knows from research that up to 5% of patients can have a migration. issue due to severe movements after surgery. Not so in his patients. This particularly important at night, when people can thrash about in their sleep.

    In ADR surgery, he implants a protective membrane to prevent adhesions between the operated area and the veins and arteries in ventral lumbar surgery. This is a look to the possible future for the patient, because it is these adhesions that make future operations in this area so dangerous. Other precautions in the approach design will serve the same purpose.

    In ADR surgeries, he packs the surgery site between and around the vertebrae with anti-thrombin agents to efficiently inhibit thrombin-induced fibrin formation and platelet aggregation.

    In ADR surgeries, he has established approach protocols. For example, in L5/S1 only ADR surgery, the surgeon should enter from the right.

    In ADR surgeries, he is chiefly responsible for the design of the implementation tools.

    The removal and the controlling of bleeding makes for a better healing process and less of a scar. This takes time and care. Most of this work is done during the incision and approach. In all surgeries, he uses the latest effective tools and equipment to ensure a better outcome.

    In Dorsal Pedicle Implants (DPI), he splits the muscles rather than cut them and remove them from the bone, which is the normal method. This is done with one exterior incision and two interior incisions. Of course, this makes the recovery for the patient much easier.

    In Dorsal Pedicle Implants (DPI), again we see many hospitals and doctors not using fluoroscopes in this procedure, which have led to many terrible mistakes.

    The removal and the controlling of bleeding makes for a better healing process and less of a scare. This takes time and care. Most of this work is done during the incision and approach.

    Does this cost a little more? Of course, but a little more cost should not dissuade us from excellent medical treatment. After all, we only have one back.

    OUTCOMES:

    Many doctors claim to be the best in their fields. Look for peer reviewed scientific articles about surgical outcomes to prove a doctor’s claims. Look for data gathering by the doctor after the surgery, to see if the doctor is engaged in scientific studies.

    THE DIAGNOSIS:

    Every good surgical outcome begins with a good diagnosis. Every intervertebral disc space and sometimes each bone of the spine should be analyzed independently and with respect to the entire spine. If surgery is required, the surgeon should have mastered the broadest spectrum of viable surgical options, which can apply to patient’s condition, and he/she should know how and when to apply them. Application of that treatment by the surgeon must be done with greatest attention to detail and organization as possible. Although the patients know of difficulties with the spine because of the nerve impingements and the consequential pain, the underlying problems of the spine are almost never solely neurological, but mechanical. Therefore, the understanding of the mechanical forces at play is critical to the precision needed to analyze and apply one or more of the modern spine surgery techniques.

    THE SURGEON:

    The foreign patient should know that Prof. Dr. Bertagnoli always performs the operation on the foreign patients. The operation is never delegated to another surgeon.

    The surgeon, of course, is the key factor. One must look at the training and experience of the surgeon. Academically, one should also look for a surgeon, who publishes scientific articles about the techniques he/she is employing. If the surgeon is teaching other surgeons about the techniques, then you can be sure he is the intellectual and surgical master of his profession. And in the modern world of spine surgery a mechanical engineering background is a plus for the doctor.

    Historically, spinal surgery had only a very restricted set of techniques available (basically discectomy and dorsal fusion) – hence only obtuse solutions were available to the patients. However with the advent of so many new technologies for the spine, this is no longer the case. Each intervertebral disc space must be analyzed for the best solution for that intervertebral space. No longer is the answer simply discectomy or fusion. Therefore, the patient should be seeking a surgeon who has experience with all the new and proven techniques, such as, artificial disc replacement, zero profile fusions, dynamic stabilization system, interlaminar decompression, discectomy with Barricaid and so on. Fortunately, Prof. Dr. Bertagnoli has been at the forefront of these technologies. His training as a mechanical engineer before he became a doctor has proven to be essential in the development in some of these technologies, but more importantly in the correct application of these technologies to the individual patient.

    The superior surgeon must also be willing to reject new technology, which does not prove to be of benefit to the patient. Just because it is new, does not make it better. Also, a truly great surgeon must have superior manual skills in the OR. For the Internet browser this is very difficult to know. Only references by experienced observers can help the patient selecting the doctor with this factor.


    HOSPITALS AND STAFF:
    Before and after the operation the hospital and staff take care of you. Members of that staff are the anesthesiologist, nurses and physical therapist. Again, experience with spine surgery patients is important for a good outcome.