Published in "Panorama"
What is Transpedicular Surgery
Prakash fell from a tree, following which he got paralysed in both legs, lost control of the bladder since the nerve controlling this was damaged in the fall. Fortunately for him, with timely surgical intervention, he is back to near normalcy today and has resumed work as a farmer,
Thanks to Transpedicular surgery, this has been made possible, say Dr.H.S.Chandrashekar, Consultant Orthopedic Surgeon and Dr.H.V.Satish Babu, Consultant Neurosurgeon, Sanjay Gandhi Accident Hospital and Research Institute, Bangalore. The good news is, such surgeries are now being performed at Welcare Hospital, Dubai, says Dr.Arne Sahlstrom, Specialist Orthopedic Surgeon, Welcare Hospital.
Done all over the world, Transpedicular surgery is one of the most successful surgical techniques in recent times for treating scoliosis, tumors, discs, spondylolisthesis and trauma, say Drs.Chadrashekar and Babu.
Dr.Sahlstrom elaborates the indications for this surgery: “Congenital spondylolisthesis in the young which gives rise to severe pain and sciatica of the legs. This is a rather common congenital disorder that we find in 5-6% of people in any given population in the world. About 20% of these will develop symptoms while the other 80% remain symptomless and are not even aware of the disorder. However, these 80% of people continue to live normal lives and can participate in any kind of sports activities as well. In those people who do reveal symptoms, we wait for the youngsters’ skeletal muscles and system to mature completely before undertaking the surgery.”
A second category of people who require transpedicular surgery are those above 35 years of age, who suffer degeneration in their discs (Degenerative Spondylolisthesis) and reveal symptoms similar to those with congenital spondylolisthesis.
Surgery is again suggested for trauma victims with a burst fracture or unstable fracture. Dr.Sahlstrom explains, “Unstable fractures often involve neurologic injury, that is, loss of vertebral height more than 50%.”
A fourth category of patients who find relief with the surgery are “the people who get metastasis from other cancers. They can be kept walking and ambulatory for the remainder of their life with the help of transpedicular screws and constructs. Without this, the spine will collapse and the patients will be lame in the legs and bedridden for the last months or years of their life,” explains Dr.Sahlstrom.
What is transpedicular surgery and what does the procedure involve? Dr.Babu explains, “The spinal column comprises 33 vertebrae and each vertebra has got a body from which we have projections called pedicles which come and meet to form the spinous process. Through the pedicle, we put screws into the body of the vertebra which will have a greater ‘purchase’ or stronger hold over the bone which had become unstable for whatever reason. Pedicle screws can be used alone or in conjunction with other implants These titanium screws are placed from the back into the pedicles. The bone is prepared by drilling, to drive in the screws. Two screws are placed into each bone, one in each of two pedicles. Rods are then attached to the screws and the disc space is spread apart and the rods are secured to the screws to hold the spine in its new position. Bone graft is then placed outside the pedicle-screw-rod assembly to bring about fusion and healing of the bones.” Dr.Sahlstrom adds, “One or more segments of the spine may be thus treated. We then add the bone transplant which is the actual healing that is needed.”
For the bone transplant itself, Dr.Sahlstrom explains, “We try to do as much as possible out of the patient’s own bone, usually taken from the iliac crest, back and front (thigh area). If this is not enough, we can add bone from the bone bank or even use certain constructs of hydroxyapatite, enhanced with bone growing proteins which enhance healing, available in the market.”
How safe are transplants done with bones obtained from the bone bank? “While we cannot compare these to the patient’s own bones, bones obtained from the bone banks are safe. Rejection is not a problem and in fact they do not need to be taken from a person belonging to the same blood group. In the first place, bones belonging to patients with certain disease conditions like cancer, HIV, AIDS are not taken by bone banks,” assures Dr.Sahlstrom.
As for the synthetic bones available, the material, hydroxyapatite is actually not a foreign material since it is normally present in the normal bones of human beings. The transpedicular screws used are made of an alloy of titanium which is bio-friendly and does not cause any reaction in the body, emphasizes Dr.Sahlstrom.
The actual duration of surgery may take between 2 ½ to 7 hours, depend upon how extensive the problem is, how many levels of vertebrae need to be stabilized with the procedure.
The surgery is contra-indicated when there is ongoing infection. This, however, is temporary till such time that the patient is free from the infection. The true contra-indication to the surgery is in case of cancer patients with short life expectancy and in the elderly with severe osteoporosis, explains Dr.Sahlstrom.
What about mobility of the region following surgery? Dr.Sahlstrom responds, “The mobility where the surgery is performed is nil. However, the patient will not notice any stiffness unless 3 levels of the spine are fused. If the surgery has been performed only in one or two levels, the remainder of the spine compensate for these two levels as a result of which the patient does not notice or feel the immobility at the one or two levels.”
How long does healing take place following surgery and what are the kind of activities these people can go back to? Dr.Sahlstrom is reassuring: The healing process is generally 3 months and after this period, we require another 3 months to rehabilitate the patients with physiotherapy, to strengthen their muscles again. Usually, in the younger patients with spondylolisthesis which is almost never more than at one level, they can go back to any activity including sports as there are no restrictions whatsoever. In fact, the younger they are, the better they do, following surgery. They lead completely normal lives and can go up to a very high sports level with very heavy work, without problems.”
What are the risks of this surgery? Drs.Chandrashekar and Babu respond “We cannot guarantee 100% success. By the side of the pedicle, you have nerves running; therefore if the surgery is not done with precision, chances are there of causing damage to the nerves which may paralyse the nerve root, leading to paralysis of that musclke supplied by this nerve root. Sometimes, this may cause irritating pain rather than paralysis to the nerve. Also, if you don’t fix it properly, there may not be good ‘purchase’; it may not have good hold over the bone. Also, if the correct length of screws are not used it may damage the artery and vein passing in the region. However, these are all extremely rare complications, unlikely to happen in the hands of a capable surgeon. Expert knowledge of anatomy is required and good orientation is called for, besides sophisticated instruments. Hence, not a lot of doctors attempt this surgery and usually major institutions undertake it.”
Commenting on the usual risks associated with any form of surgery, Dr.Sahlstrom adds, “The major risk is that of infection. You can get an infection from anywhere in the body that can cause infection over a foreign material since foreign materials in the body attract bacteria. But we take care of infections by performing the surgery under the cover of antibiotics.”
What about pain and bleeding at the surgical site? Dr.Sahlstrom replies, “Pain at the site of surgery is surprisingly little. Rather, the patient will have more pain from the bone harvest site and this is a passing pain which may last for 2-3 weeks. Bleeding is also minimum and depends on how extensive the surgery is. If surgery is only at one or two levels, these people barely ever need blood transfusion. The risk of damage to nerves is more when the surgery involves the thoracic region of the spine. But this surgery is performed under spinal cord monitoring which makes the surgery extremely safe.”
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