Year : 2018 | Volume
: 9 | Issue : 4 | Page : 219--220
From “only decompression” to “only fixation:” A century-long journey of surgical treatment for spinal spondylosis
Department of Neurosurgery, KEM Hospital and Seth GS Medical College, Mumbai, Maharashtra, India
Prof. Atul Goel
Department of Neurosurgery, KEM Hospital and Seth GS Medical College, Parel, Mumbai - 400 012, Maharashtra
|How to cite this article:|
Goel A. From “only decompression” to “only fixation:” A century-long journey of surgical treatment for spinal spondylosis.J Craniovert Jun Spine 2018;9:219-220
|How to cite this URL:|
Goel A. From “only decompression” to “only fixation:” A century-long journey of surgical treatment for spinal spondylosis. J Craniovert Jun Spine [serial online] 2018 [cited 2019 Sep 17 ];9:219-220
Available from: http://www.jcvjs.com/text.asp?2018/9/4/219/250478
The surgical strategy of “decompression” of “compressed” neural structures is a popular and widely accepted philosophy and essentially forms the basic tenet of treatment for a number of pathological entities that range from tumors, trauma, infections, and also degeneration-related issues. The word “decompression” has overpowered the psyche of the surgeons and is used for a number of treatment forms in general and spinal neural compression in particular.
Decompressive laminectomy for multilevel cervical and lumbar spinal spondylotic disease-related radiculopathy and myelopathy still continues to occupy pride of place in the treatment. Wide laminectomy and decompression of compressed neural structures forms the basis of treatment. Foraminotomy for widening of the neural canal for decompression of the traversing nerve root is currently gaining popularity. Decompression from anterior cervical route involves removal of the bulging or prolapsed disc, osteophytes, and ligamentous hypertrophy. Corpectomy and more radical form of decompression of neural structures is also a popular surgical treatment.
As the biomechanical issues regarding spinal stability became clearer and the use of metallic implant instrumentation has become popular, the surgical treatment strategy has seen significant evolution in the last few years. As “wide” bone removal from both anterior and posterior surgical routes has been identified to result in spinal instability-related issues, simultaneous surgical procedure that aims at stabilization of the treated spinal segments is a currently accepted and popular form of surgical strategy. The surgery essentially involves removal of bone, disc, osteophytes, or ligaments in an attempt to make the traverse of the neural structures free and “pulsatile.” Return of spinal/neural pulsations is generally an indicator of the success of the surgical decompression.
The strategy of decompression appears rational when the state of deformed and compressed neural structures is visually obvious on modern computer-based imaging. Observation of compressed neural structures and clinical correlation forms the indication of surgery and determines the nature of surgical strategy. Basically, guided by the symptoms, the surgical strategy is focused on rectifying the radiological image.
In the year 2010, Goel hypothesized that vertical spinal instability is due to weakness of posterior spinal muscles related to their disuse or misuse or injury., These muscles are responsible in keeping the head straight and support the human body for lifelong standing posture. The muscles act like pulleys from posteriorly, and the center of their activity is focused on the fulcrum of facets of the articular joint. Muscles located anteriorly are relatively flimsy and act more as stabilizers. Vertical spinal instability results in listhesis of inferior facet of the rostral vertebra over the superior facet of the caudal vertebra.,, Progressive instability and telescoping initiates a cascade of alterations in the spinal segment. Essentially, it was observed that instability is the primary spinal event, and all the other so-called pathological changes such as reduction in the disc height, disc bulge, ligamentous buckling, and its related osteophyte formation are a response or secondary effect of vertical instability-related listhesis. On the basis of this understanding, we suggested “facetal distraction” as treatment for degenerative single or multiple segmental radiculopathy and/or myelopathy., We identified that a single maneuver of facetal distraction using Goel facet distractor or spacer results in the reversal of telescoping and instability and reverses all the described pathological events of degenerative spondylosis. There is a stretch reversal of buckled ligamentum flavum and posterior longitudinal ligament, increase in disc height, and increase in spinal and neural canal dimensions, and there is a potential for regression of osteophytes. Essentially, it suggests that other than facetal listhesis, all other identified events that are related to spondylosis are not primary events, but are secondary processes and are reversible. Our remarkable clinical outcome following facetal distraction treatment was a testimony of effectiveness of the proposed surgical treatment.
On the basis of our further experience, we realized that the neural structures have a remarkable elasticity and plasticity and ability to modulate themselves against indenting or deforming structures, particularly in situ ations that are long standing, subtle, and slow progressive. The symptoms are relatively marginal in nature in cases with a benign intraspinal tumors such as schwannomas and meningiomas that may occupy a large part of the spinal canal and despite the frequently encountered severe cord deformation and compression. Patients with syringomyelia may have neural structures that are reduced to a thin shell around the syringomyelic cavity, yet the related symptoms may only be marginal. We recently identified that spinal cord “atrophy” may by itself be an evidence of spinal instability., The manner in which the spinal neural structures get rid of the “less” important neural structures and retain structures that are more crucial to vital functions appears to be one of the most fascinating tricks of nature.
As we matured in the understanding of the processes of spinal degeneration, we identified that subtle instability-related microtrauma is the cause of clinical symptoms rather than the neural compression or deformation. It was identified that the instability of the spinal segment is the nodal point of pathogenesis of morphological alterations in the spinal canal that are labeled as degenerative changes. Accordingly, our surgical philosophy changed and we resorted to “only fixation” as the mode of surgical treatment for degenerative spondylosis of the entire spine.,, We resorted to transarticular method of screw fixation of the affected spinal segments. The near “dramatic” clinical outcome that is most often observed in the evening of operation was a clear suggestion of effectiveness of the procedure. No decompression of any kind was done. No bone, soft tissues, discs, or osteophyte removal was done. Only fixation as a form of treatment was done even for herniated or prolapsed disc., The herniated part of the disc was not handled or removed. The concept was based on the understanding that disc herniation was a result of or a cause of spinal instability. Other than fixation of the subaxial spinal segments, it was identified that atlantoaxial joint instability can be a major participant or even a primary initiator of the entire process of spinal degeneration. It was observed that ignoring atlantoaxial instability could be a major cause of failure of surgical treatment.
Essentially, only fixation of the affected spinal segments appears to be a rational form of surgical treatment. Both direct and indirect decompression of the neural structures does not seem to be necessary.
|1||Goel A. Facet distraction-arthrodesis technique: Can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2011;2:1-2.|
|2||Goel A. Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration. J Craniovertebr Junction Spine 2010;1:65-6.|
|3||Goel A. Vertical facetal instability: Is it the point of genesis of spinal spondylotic disease? J Craniovertebr Junction Spine 2015;6:47-8.|
|4||Goel A, Shah A. Facetal distraction as treatment for single- and multilevel cervical spondylotic radiculopathy and myelopathy: A preliminary report. J Neurosurg Spine 2011;14:689-96.|
|5||Goel A, Shah A, Jadhav M, Nama S. Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: Report on a preliminary experience with 21 cases. J Neurosurg Spine 2013;19:672-7.|
|6||Goel A. Not neural deformation or compression but instability is the cause of symptoms in degenerative spinal disease. J Craniovertebr Junction Spine 2014;5:141-2.|
|7||Goel A, Dhar A, Shah A, Jadhav D, Bakale N, Vaja T, et al. Central or axial atlantoaxial dislocation as a cause of cervical myelopathy: A report of outcome of 5 cases treated by atlantoaxial stabilization. World Neurosurg 2019;121:e908-16.|
|8||Goel A. Is focal spinal cord “atrophy” an evidence of chronic spinal instability? J Craniovertebr Junction Spine 2017;8:295-6.|
|9||Goel A. ‘Only fixation’ as rationale treatment for spinal canal stenosis. J Craniovertebr Junction Spine 2011;2:55-6.|
|10||Goel A. Only fixation for lumbar canal stenosis: Report of an experience with seven cases. J Craniovertebr Junction Spine 2014;5:15-9.|
|11||Goel A, Goel AA, Satoskar SR, Mehta PH. Double insurance transfacetal screws for lumbar spinal stabilization. J Craniovertebr Junction Spine 2014;5:85-7.|
|12||Goel A, Dharurkar P, Shah A, Gore S, Bakale N, Vaja T, et al. Facetal fixation arthrodesis as treatment of cervical radiculopathy. World Neurosurg 2019;121:e875-81.|
|13||Goel A, Dharurkar P, Shah A, Gore S, More S, Ranjan S, et al. Only spinal fixation as treatment of prolapsed cervical intervertebral disc in patients presenting with myelopathy. J Craniovertebr Junction Spine 2017;8:305-10.|
|14||Goel A. Can decompressive laminectomy for degenerative spondylotic lumbar and cervical canal stenosis become historical? J Craniovertebr Junction Spine 2015;6:144-6.|