SPINE SURGERY

LUMBAR DISC HERNIATION

Our vertebral column consists of 33 bones each named “vertebra”. There are 5 vertebras in our lumbar region. When the vertebras are aligned on top of each other, there becomes a big canal in the middle, which is called “spinal canal” and contains the spinal cord. Also, at each level, there is a small hole on each side called “foramen” which is the outlet for the nerves originating from the spinal cord and travelling to our extremities. Between each vertebra there is a pillow called “disc” which consists of a soft interior and hard & elastic exterior.

Lumbar disc herniation can be described as tearing of this hard & elastic exterior and protrusion of the soft interior. If this protrusion is toward the spinal canal, it compresses the spinal cord; if it is towards the foramen, it compresses the nerves of our legs. Usual complaints are low back and leg pain, generally referred as radicular pain. Diagnosis is established by physical examination and MRI scan.

Lumbar disc herniation is a rather common disorder and only a minority of patients require surgery. First approach to treatment is bed rest and analgesics. If this is not sufficient, physical therapy is initiated. Local injections can be used in selected patients.

In case of failure of all the above measures or loss of muscle strength, operation becomes the only treatment. Standard surgical procedure is “lumbar microsurgery” if it is a simple herniation and not associated with any other condition. In this procedure, a small window is opened in the vertebra and the herniated disc material is removed under microscope, avoiding any damage to the surrounding nerves. After lumbar microsurgery, patient is mobilized within hours and discharged the next day. The rate of partial loss of muscle strength as a complication is less than %1 and the rate of recurrence is less than %3 with microsurgery.

BURAK O. BORAN, M.D.

CERVICAL DISC HERNIATION

Our vertebral column consists of 33 bones each named “vertebra”. There are 7 vertebras in our cervical region. When the vertebras are aligned on top of each other, there becomes a big canal in the middle, which is called “spinal canal” and contains the spinal cord. Also, at each level, there is a small hole on each side called “foramen” which is the outlet for the nerves originating from the spinal cord and travelling to our extremities. Between each vertebra there is a pillow called “disc” which consists of a soft interior and hard & elastic exterior.

Cervical disc herniation can be described as tearing of this hard & elastic exterior and protrusion of the soft interior. If this protrusion is toward the spinal canal, it compresses the spinal cord; if it is towards the foramen, it compresses the nerves of our arms. Usual complaints are neck and arm pain, generally referred as radicular pain. Diagnosis is established by physical examination, EMG and MRI scan.

Cervical disc herniation is a rather common disorder and only a minority of patients require surgery. First approach to treatment is bed rest, collar and analgesics. If this is not sufficient, physical therapy is initiated. Local injections can be used in selected patients.

In case of failure of all the above measures or loss of muscle strength, operation becomes the only treatment. Standard surgical procedure is “anterior cervical microsurgery” if it is a simple herniation and not associated with any other condition. In this procedure, a small incision is made in the natural crease of the neck and a corridor is opened between the carotid artery and the windpipe. The herniated disc material is removed under microscope, avoiding any damage to the surrounding nerves. Following the removal of the disc, a stabile cage or a dynamic prosthesis can be inserted between the vertebras. After cervical microsurgery, patient is mobilized within hours and discharged the next day. The rate of partial or total loss of muscle strength as a complication is less than %1 with microsurgery.

BURAK O. BORAN, M.D.

SPINAL STENOSIS

Our vertebral column consists of 33 bones each named “vertebra”. When the vertebras are aligned on top of each other, there becomes a big canal in the middle, which is called “spinal canal” and contains the spinal cord. When the vertebras start to degenerate due to aging, pathological bone formation may compromise the spinal canal. Compression of the spinal cord in the spinal canal due to vertebral degeneration is called spinal stenosis.

Stenosis can occur anywhere in spina. If it is in the lumbar region, the patient complains of low back and leg pain, loss of muscle strength in legs, in ability to walk long distances, etc. If it is in the cervical region, the patient complains of neck and arm pain, loss of muscle strength, inability to hold objects in hand for long time, etc. If it progresses, legs may become stiff and walking can be a problem. Diagnosis is established by physical examination and MRI scan.

This disorder cannot be treated with conservative treatment; therefore, surgery is required whenever the situation interferes with daily activities. In surgery, bones compressing the spinal cord are removed. If a small region is involved, this is the only required treatment. But if a more extensive involvement exists, screw fixation is required after decompression. Both stabile systems and dynamic systems can be used, depending on the physical activity level of the patient.

BURAK O. BORAN, M.D.

SPONDYLOLISTHESIS

It is the slipping of one vertebra on another. When such a slip occurs, spinal canal becomes compromised and spinal cord compressed. Therefore, the treatment is surgical. In surgery, spinal canal is decompressed, and the slipped vertebras are aligned and screwed.

BURAK O. BORAN, M.D.

VERTEBRAL FRACTURES

We can roughly divide vertebral fractures into three: First type is traumatic. If there is spinal cord compression and/or vertebral column instability, patient should be operated immediately.

Second type is compression fractures due to osteoporosis we commonly see in elderly. These generally do not require surgery; bed rest and orthotic braces are sufficient. In rare cases, if the pain is unbearable, “methyl methacrylate” can be injected into the broken vertebra which is called vertebroplasty or kyphoplasty, depending on the type of surgery, which is a mini surgery.

Third type is pathological fracture, generally due to metastatic tumors. Surgery may be required for biopsy, decompression of spinal cord or stabilization of the vertebral column. But the treatment of metastatic tumors of the spine is not surgical. Required treatment is radiotherapy.

BURAK O. BORAN, M.D.

PEDIATRIC NEUROSURGERY

SPINA BIFIDA

Spina bifida is the name of a group of congenital spinal cord anomalies. It occurs due to the lack of proper congenital development of spinal cord and vertebral column.

If we roughly divide these into two, first group can be called “open” anomalies. This group consists of myeloschisis, meningomyelocele, etc., which is briefly a situation in which the baby is born with his or her spinal cord out in the open. It requires immediate surgery. First 24 hours is valuable. These babies are generally born with partial or complete paralysis below the waist. Surgery is the only chance to protect what is available and to eliminate the risk of meningitis.

Second group can be called “closed” anomalies. This group consists of tethered cord, dermal sinus tract, diastometamyelia, diplomyelia, etc. These babies generally manifest a skin finding such as a dimple in the sacral region or extensive hair in the low back. Diagnosis is established by physical examination and MRI scan. Surgery is essential but not urgent. In these anomalies, spinal cord is generally tethered at some level and as the child grows in height, the cord stretches leading to urinary incontinence, partial paralysis in lower extremities, etc. Therefore, the timing of the surgery should be well calculated.

BURAK O. BORAN, M.D.

HYDROCEPHALUS

There is a liquid called cerebrospinal fluid, circulating in and around our brain and spinal cord. If its circulation is blocked, if it is under absorbed or over produced, it starts to accumulate in the voids of brain called ventricles. Enlargement of these ventricles is called hydrocephalus.

Treatment is surgical. Most common surgical procedure is insertion of a ventriculoperitoneal shunt, which is a silicone tube, draining the excess cerebrospinal fluid to the intraperitoneal space. In selected cases endoscopy can also be used.

BURAK O. BORAN, M.D.

CRANIOSYNOSTOSIS

Every baby is born with gaps between the skull bones, which we call sutures. Skull grows vertical to these sutures. If one of the sutures closes early, growth stops in that direction but continues in other directions resulting in a skull shape anomaly, called craniosynostosis.

This is essentially a cosmetic problem. If not all the sutures close prematurely resulting in a small skull, brain development is not affected. But studies show that, anomalies in skull shape is associated with bullying in school age, which affects the psychological development adversely.

Therefore, if there is any suspicion, the baby or child should be examined by a neurosurgeon. Diagnosis is established with physical examination and 3-dimensional CT scan. Treatment is surgical. Surgery is easier if performed earlier in life and the results are better cosmetically.

BURAK O. BORAN, M.D.

CHIARI

Cerebellum is in the posterior fossa of our skull. Sometimes it hangs downwards, leaving the skull and entering the spinal canal, compressing both itself and the supper spinal cord. This is called Chiari syndrome. Type 2 is seen in babies and type 1 is seen in young adults, although it is congenital.

Main complaints in type 1 Chiari syndrome are vertigo, unbalanced gait, weird sensations in arms and stiffness of legs. Treatment is surgical. A small bony window is opened in the lower back skull to decompress both the cerebellum and the upper spinal cord.

BURAK O. BORAN, M.D.

TUMOR SURGERY

Surgery is the first and the most important step in the treatment of brain and spinal cord tumors. If it is a benign tumor, it is also the only treatment. If it is a malignant tumor, radiotherapy and chemotherapy can also be needed. But whatever the case is, benign, malignant or metastatic, surgery is a must; because, if we do not remove the tumor, patient can be lost due to intracranial hypertension instead of cancer.

Most important progresses in tumor surgery in the 21st century is the increasing knowledge of nervous system anatomy, expertise in microsurgical techniques and development of skull base approaches, which give the opportunity to reach once unreachable tumors. All these make it possible to remove tumors without injuring the neighboring nervous tissues.

BURAK O. BORAN, M.D.

PERIPHERAL NERVE SURGERY

Nerves that originate from the spinal cord and reaches to extremities are called peripheral nerves. They can be cut, torn apart or trapped along the way. There can also be tumors of these nerves. Surgical treatment of these disorders are collectively called “peripheral nerve surgery”.

Entrapment neuropathies are the most encountered disorders. In these disorders, a peripheral nerve is entrapped, while passing through a canal or a tight space. These commonly occur at joints such as wrist, elbow, knee or ankle. The patient experiences sensory or muscle strength loss in the extremity supplied by that nerve. Most common mistake made in these patients is confusing the situation with disc herniation. Diagnosis requires a physical examination done by an experienced neurosurgeon and an EMG study. Most of the surgical procedures are mini surgeries performed under local anesthesia.

BURAK O. BORAN, M.D.