DIFFERENCE IN TRADITIONAL AND GORE SYSTEM OF SPINE SURGERY

Transcript of above video:

Hello! Greetings from Dr. Gore from Pune, India. I am going to explain to you in very simple plain English about the various things which are done as a surgeon in the lumbar spine, that is the lower part of the back.

As you are aware, the lower part of the back has got 5, 5 lumber vertebrae, like this – this is one, this is second and what we have is the lumbar vertebra –
this is what is called as the body,
this area is called as the pedicle,
this area is called as the transverse process,
this area is called as the lamina
and this area is called as the spinous process,
this area is called as the facet.

Now, one vertebra attaches with the other vertebra and makes the whole vertebral column.

These two facets make the joint called as the facet joint and in a vertebra this is the back side of the vertebra and this is the front – the abdominal, the belly side of the vertebra.

Here you will find a ring like structure which is – in this model white or yellowish and a reddish sort of centre which is jelly. This is called as annulus which is ring, and this is called as nucleus which means centre.

Normally in a person this annulus is intact.

What happens is in some people this annulus breaks down as you can see here and some portion of this central area which is normal here comes out and then this starts pressing against the nerve which is seen here – the yellow. This is the spinal cord and the nerves are coming out where this will press the nerve.

Now this nerve will get swollen and will get compressed and give rise to leg pain or sciatica.

In some patients there are changes which are related to this facet joint, this is the back side, this is the front side and the changes in the facet joint are such that the changes here will slowly start pressing on the nerve from the back.

This change where this area through which the nerve is coming out is called as Lumbar Canal Stenosis. In simple English it means the narrowing of this path of the nerve because of causes commonly at the back of the nerve. This thing where the portion of the nucleus has come out is called as a slipped disc or a prolapsed disc or a herniated disc. This is the disc herniation. This commonly gives leg pain. The stenosis or the narrowing gives what is called as claudication – that is now how do you treat after you walk for a certain distance your legs go numb and you not able to walk further which is called as claudication.

Now how do we treat this? As you are aware spine surgery has been in existence in the modern world since 1932-1934 till today. It’s almost 84 years now that spine surgery has been done in the modern sense of the world.

What we do is in the past what we needed to do is to reach this area – we used to cut open from behind – this is the back, so we used to cut open, we used to remove this bone and remove this bone. This removal of the bone is called as Laminectomy.

Laminectomy is removal of this portion and this flat portion, that is, the spinous process
and the lamina
and the spinous process below
and the lamina
and the tissue in between and above what is called as supraspinous ligament, interspinous ligament,
ligamentum flavum, lamina, spinous process all these things are removed.

Why?
Because once you remove them, let’s say we have removed it like this, then we go in and explore where is the cause of pain. We will push this nerve to one side and try to see if this material is sitting here.

In the past as you know since the MRI scans where not available the location of this slipped disc or herniated disc was not seen by the eyes and the only way for us to know this location of the offending part of the disc was to open it from behind and explore it. So in the past, the surgery was laminectomy and what we call as exploratory discectomy and it involved a morbid removal of all this material which naturally used to make the spine unstable and while exploring we used to handle this quite a lot which used result in the weakness of the spinal cord, of the nerves which control the urinary function and the nerve which goes down the leg and the patient used to land up with more weakness many times after the surgery.

The another thing is there are many blood vessels here so during open surgery there is a lot of bleeding which may have to be replaced by giving blood transfusion.

Now what is it that has changed?
The major change is in the form of imaging number 1.

So, what we do is, we have a MRI scan which shows us all these things in all possible perspectives – that is, there a scan like this which is called Coronal, there is a scan like this from the side called as Sagittal, and there is a scan like this which is called as a Cross Section.

So, without even touching you I can tell you where your problem is situated.

Now when we started using the MRI scan the basic question was this change which I see – is this the cause of my pain? Now that I have started seeing this – I know it is there but to answer the question is this causing the pain in this nerve needed some more time to answer this question.

What I have started doing is around 1999 we started operating all our patients under local anaesthesia and what I do is looking at the MRI scan and this substance which is pressing the nerve I go in this area what we call as a Foramen with a needle and then I push my endoscope or a small telescope inside this area.

This endoscope has the ability to tackle everything which lies in front of it because it has a camera and light source attached to it.

So, when I put the scope inside like you can see here in this diagram – you can see there is a small cut here, your which is shown on the back. So we do not operate in the midline or the back, we do not cut the back open, we go here on the side as the arrow is pointing and at that place I put the scope inside – it goes next to this cause, I remove this cause – grab it and pull it out and the nerve becomes free.

Now, since I am doing this surgery under local anaesthesia for almost 19 years now – now we know which structure causes pain where. Because all my patients during the surgery are absolutely awake and aware. I mean there is no anaesthesia.

So, there are two important changes that we have brought in the surgery –

without removal of any bone here I can land here, push the nerve away and remove this substance under local anaesthesia that is when the patient is fully awake – I can do this.

Now, in case of stenosis as I said where this area is narrow, we in simple language say that instead of cutting open all this and then going here and making this bigger, it is more easy coming from outside like this and doing the job with various mechanical drills or laser so that we can remove everything which is obstructing the passage of the nerve. So, this is called as Foraminoplasty and what we do with the scope is called as Endoscopic Surgery.

So remember –
we do not touch this area,
we do not destabilise the spine
and therefore, there is no need for us to put the screws here on both the sides and fix it with a rod.

Fixing with a rod and putting the screws is absolutely unnecessary. It is done mainly to make your spine which becomes unstable by the surgery. The instability or the movement which occurs during the surgery and because of the surgery are treated by the screws.

Since we do not cause unsteadiness here, we do not need any instruments, any screws inside.

And I will just repeat once again that our surgery is stitchless and under local anaesthesia and it can be a day care procedure that is, the moment you operated in the morning the same day evening you can go home.

So, in short what we have done is we have a stitchless under local anaesthesia solution to your problem of pain and claudication and we take pride in the fact that we are able to answer your question where is my pain coming from and why is it persisting?

So, I think our surgery is at least three generations ahead than the open surgery where the whole thing may become unstable and you need to put screws and because of the handling you have a higher chance of paralysis or weakness of the spinal cord.

Thank you very much. I hope this is answered your basic questions which you have in your mind.

Thank you very much. Welcome.