Dr. Gold's Orthopedic Surgery Blog

Transforaminal lumbar interbody fusion, or TLIF, is a surgical procedure to fuse vertebrae together. Since the procedure creates a solid, inflexible bone “bridge,” the patient will be unable to bend his back at the spot where the fusion is performed. TLIF back surgery is frequently used to treat herniated discs that recur repeatedly, degenerative disc disease, spondylolysis or other conditions in which the patient’s pain level might be reduced by the stabilization.

TLIF is open surgery requiring a hospital stay of three to five days. The patient will normally begin physical therapy within 24 hours of the surgery, but initial activity will be limited. Many patients must wear a brace for all or part of their recovery

. After discharge, patients will receive pain medications to take at home and will be restricted to light activities. Office workers can normally return to work in one to two months. Those whose jobs are more physically demanding typically have a longer recovery time before they can resume their normal occupations.

TLIF fuses both the posterior and anterior of the spinal column. The surgeon uses hardware and bone, if needed, to lock the posterior into place. The bone graft and spacer stabilize the anterior region.

To perform a TLIF back surgery, the surgeon will make an incision in the back to expose the spine. The disc between the two operative vertebrae is removed. The surgeon will harvest a bone graft from the patient’s hip and insert it in a cage or spacer that is inserted in the gap left by the disc he removed. He will also add bone to the sides of the disc space and the vertebrae. Plates or rods are screwed into place and the incision is closed.

Patients who have disabling leg and back pain and have failed all nonsurgical options may obtain significant pain relief from a TLIF. Studies report that 60 to 70 percent of patients undergoing the procedure indicated they experienced an improvement in their level of pain.

While TLIF normally results in reduced pain levels and solid fusion of the bone, rare complications can occur. As is true with any surgery, patients are at risk for complications from the anesthesia, excessive bleeding, damage to the nerves and infection. Patients may also develop blood clots, pneumonia, experience a stroke, or suffer a heart attack. Risks specific to the TLIF procedure include the possibility that fusion fails to occur, requiring another operation. The procedure may not alleviate the patient’s pain, and in a few rare cases, patients report their pain levels actually increased.

I hope that helps you learn more about TLIF back surgery!

Until next time,

Stuart

One of the first questions I hear from patients diagnosed with a need for surgery, “What are my options for back surgery?”

In the United States, the lumbar discectomy is the most common back surgery performed. This procedure allows the surgeon to remove the disc and other tissue that is causing pressure on surrounding nerves. The operation is often used to alleviate the symptoms of sciatica. Traditionally, the procedure was open surgery that entailed an increased risk of complications and an extended recovery period.

Over the years, new techniques have been perfected to reduce the trauma to the operative area. Minimally invasive surgical techniques employ microscopes, endoscopes and miniature instruments to visualize the spine and make the necessary repairs. The scopes and instruments are passed through one or more tiny incisions. Images are transmitted to a monitor that the surgeon uses to guide his movements. Recovery rates are faster, post-operative pain is less and the risk of complications is reduced. Many patients require only a local anesthetic and may return home the same or following day.

Laser surgery of the spine began several decades ago and has been increasing in popularity. However, many hospitals do not approve of the procedure even though a large number of these operations have been performed with few complications. The procedure is performed under a local anesthesia and the patient may be allowed up within minutes of the surgery. Patients whose occupations do not require heavy physical activity can often return to work in as little as two weeks

.

The basic technique for laser surgery utilizes the same principles as other minimally invasive procedures. A small incision is used to insert a camera and a laser. With the camera to guide him, the surgeon uses the laser to vaporize the portion of the disc causing the problem. However, the lasers are incapable of cutting through bone. This means that they can only be used on the discs.

Despite advances in microsurgery, many patients still require open surgery for back problems. One example is spinal fusion, which has an overall high failure rate when performed as a minimally invasive technique. However, some individual surgeons find their patients’ success rates are excellent. The choice of a technique is one that the patient should discuss with his surgeon and should be based on not only the patient’s preference but also the surgeon’s experience with a particular technique.

Until next time,

Stuart

Before proceeding with ankle surgery, I think it’s very important for patients to understand the anatomy and the diagnosis of a very severe sprain. That said, here is some information for you to consider….

The ankle is a complex joint consisting of three bones, which are the tibia, the fibula and the talus. Tendons connect these bones to the muscles, and ligaments connect the various bones. A sprain is an injury to one or more of these ligaments. A sprain is not the same as a strain, which involves the muscles instead of the ligaments.

An ankle sprain can result from playing contact sports or simply walking on unstable ground. During the 1970s, extreme platform shoes were credited with numerous ankle injuries. Even as simple an act as standing can cause an ankle sprain if the foot is placed incorrectly or is unstable.

Ligaments are somewhat elastic, and under normal conditions, they stretch to accommodate movement before returning to place

. If a movement or trauma exerts too much force on the ligament, it may be torn. The tear may be complete or partial, resulting in pain and instability. If the ligament is not completely detached, it may become elongated, making the patient feel unsteady on his feet or generate pain.

Physicians grade ankle sprains from one to three, with a grade 3 being the most severe. A patient with a sprain of this severity will experience a significantly swollen ankle with tenderness and instability. A grade 3 sprain is treated without surgery by casting or bracing the joint to immobilize it for two or three weeks.

If the sprain does not respond to rest, therapy and medications, or if the instability persists for several months even with conventional treatment, ankle surgery may be an option. In addition to X-rays and MRIs, the doctor may perform an arthroscopy to take a closer look at the joint to determine whether the ligament is being pinched or if there might be loose pieces of cartilage or bone.

Depending on what the examination shows, the surgeon can often make repairs with a minimally invasive procedure. Ligaments can be repaired with sutures, or a graft may be taken from another ligament or tendon to patch the tear.

Recovering from ankle sprain surgery will depend on numerous factors, including the severity of the injury and the therapy the patient receives. At best, recovery will take several weeks, and it is not uncommon for rehabilitation to last for months. A complete return to stressful or high-impact activities can take up to a year, although some patients may find they will never be able to resume such strenuous activities.

I hope this better helps you understand the reasons you may need surgery for a sprained ankle.

Until next time,
Stuart

Prior to any surgery, I encourage patients and my colleagues to consider their alternatives. That said, here is some additional information about alternatives to shoulder surgery that might help you through this process…

Numerous conditions can cause shoulder pain and restricted movement. Arthritis, bursitis and tendonitis are common ailments. Fractures, especially those involving the collarbone or the upper arm, can have a significant impact on shoulder mobility. The cartilage may become worn or torn. A tear in the rotator cuff can also occur, resulting in severe pain and dramatic reductions in mobility. At times, surgery may be indicated for any of these shoulder problems. However, physicians often prefer to try non-surgical treatments prior to operating.

• The doctor may order non-prescription medications, such as ibuprofen or aspirin, to reduce pain and inflammation. Prescription pain relievers and muscle relaxers may follow if the patient receives no relief from over-the-counter medications. The physician may also opt for steroids, injected into various locations of the shoulder, to help alleviate symptoms and accelerate the recovery.

• Physical therapy may be beneficial for some patients. Depending on the nature of the injury, the physician may give the patient a series of exercises to perform at home. More severe cases may require a formal course of physical therapy.

• It may be necessary for the patient to modify his or her activities. If the patient can identify certain movements or stresses that precede the onset of symptoms, avoiding such activities may reduce the pain and inflammation. In some cases, avoiding the activity for a period of time can allow the injury to heal without further intervention.

Another procedure of relatively recent origin involves the injection of an irritant to stimulate the growth of tendon and ligament tissue. The technique uses the bodies own healing system to trigger an inflammatory response that can sometimes result in growth that is thicker and stronger than the natural tissue. However, the procedure cannot heal bone or cartilage. On average, most patients need three to six injections to achieve results, but it is possible that many more injections will be required

. This method has yet to be proven in long-term studies.

I hope this helps you better understand the alternatives to shoulder surgery including shoulder replacement.

Until next time,
Stuart

I see many athletic patients. Many of them are tennis fanatics. Unfortunately, over time, some patients require elbow surgery due to “tennis elbow”. To help you better understand this details of surgery for tennis elbow, please continue reading this post.

Tennis elbow, or lateral epicondylitis, is the term used to describe a painful inflammation affecting the tendons joining the elbow to the muscles in the forearm. Both the muscles and the tendons can be damaged through repetitive motions.

Those who play racquet sports, such as tennis, may be at risk for the condition, but any repetitive motion that places stress on the elbow can cause it. Therefore, active gardeners or hobbyists who work with hand tools may also develop the condition.

Prior to surgery, most patients will be advised to rest the affected arm. They may need to give up sports or restrict work activities that affect the elbow. Over-the-counter medications may be used to reduce swelling and pain. The physician may also recommend physical therapy or the use of a brace while the arm heals. In some cases, the doctor may opt for cortisone injections to bring relief. It may be advisable for those who play racquet sports to consult a professional to make sure equipment is properly sized, since a handgrip that fits poorly can exacerbate or cause strain.

Normally, conservative methods will be employed for six to twelve months before surgery is recommended. Fewer than five percent of all patients undergo elbow surgery for tennis elbow. Although arthroscopic surgery is sometimes an option, most elbow surgery for tennis elbow is open surgery. Both types can often be performed on an outpatient basis or with only one night in the hospital.

• To learn more about what happens during tennis elbow surgery, please click here.

The exact nature of the surgery will depend on the extent of damage, the patient’s overall health and the preferences of both the patient and surgeon. Most often, the operation is performed to release the tendon, remove diseased or damaged tissue and reattach healthy muscle tissue to the bone. If it is possible to reattach the tendon without stretching it too tightly, the tendon will also be reattached.

After surgery, the arm is normally splinted to keep it immobile for the first week or so. When the sutures are removed, the splint is normally discontinued. Depending on the patient’s condition, the doctor may recommend stretching exercises to increase flexibility. Strength-building exercises are normally begun about eight weeks after the surgery. A return to strenuous activities, such as sports or jobs requiring heavy lifting, may be delayed for as long as six months.

As is true with any surgery, an operation for tennis elbow carries certain risks. Infection and damage to blood vessels or nerves are among the risks. It is also common for the patient to experience a slight loss of strength in the affected arm. It may also become less flexible, and some patients are unable to fully extend their arms after surgery missing one to five degrees of motion. The best results are found in patients who follow instructions for post-operative therapy or exercises

.

I hope that helps you learn more about surgery for tennis elbow.

Until next time,

Stuart

Patients with sore or painful spines typically come into my office with questions about the different types of back surgery. That said, there are several key points a patient should consider as they consider back surgery types. Here are some ideas for both patients and caregivers:

Unless an emergency situation exists, few surgeons will operate on the spine without a minimum of three to six months of more conservative treatment. Patients may be advised to rest, alter their activities or attend physical therapy during this time. Aspirin or ibuprofen may be recommended to treat the pain, but the doctor may also prescribe more powerful pain relievers or muscle relaxers. Epidural or facet injections should also be considered or tried prior to considering operative intervention.

The type of back surgery needed depends on the nature of the injury and diagnosis. Both the severity and the location of the injury will be evaluated carefully before the surgeon makes a recommendation. If more than one technique is possible, the patient’s health, lifestyle and the surgeon’s preference will also be factors in the decision.

• A discectomy is a common procedure to correct a herniated disc. Discs are the fluid-filled cushions that are found between vertebrae. They act as shock absorbers and lubricate the vertebrae to assist with movement. The fluid within the discs can begin to leak after an injury or as the body ages. This fluid can leak out onto nerves, resulting in pressure, pain and numbness in the extremities. With a discectomy, the surgeon removes the herniated disc. Only rarely is it necessary to use a bone graft or plate to fuse the two vertebrae (on either side of the removed disc) in an isolated disc herniation. Depending on the patient’s condition and the technique chosen, outpatient surgery or a minimal hospital stay may be an option.

• A laminectomy is another procedure that may be an option for a herniated disc, although it is sometimes used to correct a bulging disc, or one that is not leaking but extends beyond the vertebrae flanking it. The procedure is most commonly used to correct stenosis of the spine

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  . In a laminectomy, the surgeon removes the back of the vertebra, called the lamina, as well as any portion of the disc that requires removal. By removing the lamina, the spinal canal has more space thus relieving pressure on the compressed nerve.

If a nerve is receiving pressure from a source other than or in addition to a herniated disc, the surgeon may elect to perform a foramenotomy. In this procedure, scar tissue or bone can be removed to free the nerve. The procedure is normally used to correct pressure on nerves at the points where they emerge from the spinal column.

Spinal fusion may be performed in conjunction with another surgery, such as a discectomy or laminectomy, or it may be performed to correct a condition such as an instability known as spondylolisthesis. The net effect of the surgery is that the spine can no longer bend where the two vertebrae have been fused. A relatively new procedure involves replacing the disc with an artificial prosthesis. Patients may have difficulty, however, in locating a surgeon with extensive experience with replacement surgery. The results of disc replacement are still being studied and remain unknown.

I hope this help you understand some of the different back surgery types.

Until next time,

Stuart

A common question I receive from patients suffering knee pain is, “Would I benefit from knee arthritis surgery?” Before I answer that question, I perform the necessary tests to understand the patient’s diagnosis

. I also make sure that my patients understand the anatomy of the knee and the surgical expectations. Here is some information that I hope helps you as well.

Arthritis of the knee causes the joint to become painful and stiff. It may take the form of osteoarthritis, which results from wear, or rheumatoid arthritis, which is an autoimmune disease. Other factors, such as infections or lupus and other diseases, notably complex fractures of the knee, can also lead to arthritis.

The knee is an important weight-bearing joint. The tibia, or shinbone, and the femur, or thighbone, meet at the knee, which operates like a hinge. The kneecap, or patella, glides over the femur tip when the knee is bent. In a healthy knee, articular cartilage covers the patella and the ends of the tibia and femur. The cartilage reduces friction when the joint moves.

With osteoarthritis, the cartilage cushioning the bones becomes eroded. This allows the ends of the bones to grind against each other. The cartilage may be thinned, due to disease, or it may be completely missing. Bits of cartilage may be left to float inside the joint, causing additional pain.

Rheumatoid arthritis leads to inflammation of the surrounding synovial membrane. Eventually, it will destroy the cartilage. Adjacent bone may also become soft and damaged.

In the early stages of knee arthritis, anti inflammatories i.e. Motrin, naprosyn, etc, are effective. Injections used appropriately like cortisone and viscosupplementation are helpful in some patients.

If the patient’s condition involves severe pain and marked lack of mobility, a surgeon may recommend knee replacement surgery. Each patient must make an informed decision, after consulting with his physician, regarding knee replacement surgery. The operation has a success rate of approximately 96 percent, and has become one of the more routine procedures that orthopedic surgeons perform.

To replace the knee, the surgeon makes an incision and exposes the joint. The ends of the femur and tibia are removed. Only a minimal layer of bone is removed, which is replaced with two layers of metal and a plastic spacer. If needed, a layer of plastic is applied to the back of the patella. These replacement components are cemented into place in most cases.

The knee has both and outer and an inner compartment. It is possible for only one of these compartments to be severely damaged. A unicompartmental or partial knee replacement addresses only the damaged compartment. Recovery time may be shorter and the patient may obtain an improved range of motion.

Rarely, a patient may opt to have the femur and tibia fused. This procedure is referred to as a knee fusion. The procedure leaves the patient with total and permanent stiffness of the joint. Few patients willingly choose to deal with the inconvenience such stiffness causes. However, if a successful fusion is achieved pain relief is excellent.

Arthritis can cause the legs to bow, which can accelerate the degeneration. An osteotomy changes the leg’s alignment. The surgeon makes an incision and then cuts either the femur or the tibia so he can realign the leg and unload the more diseased compartment. The procedure is usually recommended only for younger individuals whose arthritis is not yet advanced and who still have a good range of motion. While the procedure can alleviate pain, most patients eventually will have the joint replaced.

Until next time,
Stuart