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What are your thoughts on these please?
Expandable cages might have their place but I generally don’t endorse them for two reasons. First is that this cage can place undo pressure on the endplate due to the force of the expansion mechanism. This force can fracture the endplate which exposes cancellous bone of the vertebral interior. This in turn can cause osteolysis if the surgeon uses bone morphogenic protein. The endplate fracture can also allow recession of the implant into the body of the vertebra-losing the distraction important in realignment.
The second problem is that the mechanism of distraction, some type of “screw-jack” mechanism takes up space that could be occupied with bone graft. This reduction of bone graft makes fusion less likely and might slow fusion down.
Dr, Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.many surgeons are now recommending MIS TLIF with BMP in a V shaped expandable cage for isthmic spondylolisthesis?
The thought is that there is less muscle stripping and lordosis is better with expandable cage, in addition BMP will fuse faster, however no posterolateral fusion.
I have read your previous comments about MIS TLIF and it is interesting to hear about the expansion mechanism causing endplate fracture.
Most surgeons would probably never admit to expansion mechanism causing fracture.
Do you still feel the same about MIS TLIF with BMP ?
Thank you
The muscle stripping argument for MIS surgery has always had me mystified. The muscles that are “stripped” are really not stripped but I will deal with that argument here later. Lets assume that these muscles are “stripped”. The question is, how does that affect the surgery and the post-operative success? These muscles are local muscles. That is, they originate from the sacrum and insert onto L5. Aren’t these the segments that are intended to be fused? How does “saving” these muscles help the final results of surgery? The whole point is that these segmental muscles will be useless once the L5 vertebra is fused to the sacrum so thinking that saving them is better is really magical thinking.
The other point is that these muscles are not “stripped”. You can do the same surgery in a smaller central incision than you can with the two larger “minimally invasive” surgical scars and you don’t have to strip the muscles. I do not endorse this technique, however. You need to clear the transverse processes and lateral edges of the facets to place bone graft here to allow a fusion to occur in this area. This fusion mass reenforces the surgery and on occasion will lead to a solid interbody fusion where one might not have occurred originally without the posterolateral fusion. I am currently writing a paper on this phenomenon.
The expandable cages is not beneficial as I had noted in the previous post. The work of distracting the two endplates should have been performed before the cage is inserted. It takes some surgical work but is much safer than the expandable cage.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Thank you and I whole heartedly agree with all of your points.
With regard to muscle stripping, I sense that surgeons like to avoid open back surgery from a pain stand point. Most will say that muscle stripping or open incision is a long, painful recovery and residual scar tissue with midline incision can cause pain indefinitely.
Thoughts ?
My central incision is about 1/2 the length of the “minimally invasive” surgery incisions. The pain is not generated from the muscle but from stretching the collapsed annulus that is typical with all fusions for degenerative discs. If the disc height is not restored, there is less pain but less restored alignment.
The midline incision causing pain is a myth propagated without any reliable studies. There is no more or less pain in a TLIF than with a minimal central incision. I use the MIS technique for lumbar far lateral microdiscectomies. There is no more or less pain than a central incision microdiscectomy. The information that MIS surgeons propagate is just not correct. I am currently writing a paper on this misinformation.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books. -
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