All Posts in Category: Minimally Invasive Surgery

Legacy Updates!

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Important Announcements To Legacy Spine and Neurological Specialist’s Patients

While 2020 and 2021 have been very challenging and unprecedented years, we do have some very good news to brighten the day of all our Legacy team and patients!

Kelli Schlesinger MD and I are excited to announce that Dominic Maggio MD Neurological Surgeon will be joining our Legacy practice in July.  Dr. Maggio joins us from his complex spine fellowship at Ohio State University and his neurosurgery residency at University of Virginia, Charlottesville.  He comes with tremendous training and experience  from two of the best neurosurgery  training programs in the country.  He is a very talented neurosurgeon with expertise in minimally invasive and complex spinal surgery.  He will be moving to Little Rock with his lovely family with 3 young children.

We will continue to offer telehealth services for the foreseeable future to facilitate your treatment plan, particularly those of you who live long distances away. We are excited about some new MIS technology and innovation‘s coming our way this year and in continuing to use our outpatient minimally invasive SLIF surgery (Screwless Lumbar Interbody Fusion) when a fusion surgery is needed on the lower back through a key hole incision.   For the last four years we have worked with some innovative spinal companies and imaging technology companies to develop the most minimally invasive lumbar fusion surgery option that is available anywhere in the world!

 

Additional developments:

In May, Dr. Flaxman and Dr. Magnuson, anesthesia pain management doctors of Southern Regional Anesthesia Consultants (SRAC), will be joining our team in performing injection procedures at the Legacy Surgery Center.  They also offer medical pain management services at their office for patients needing medication management.

Dr. Carlos Roman, an anesthesia pain provider of Proper Pain Solutions (PPS) will no longer be performing procedures at Legacy Surgery Center.   However, his pain management partner Dr. Eugene Becker will be performing injection procedures on patients we have clinically shared with PPS at Legacy Surgery Center.

Notice:     PPS Drs. Roman and Becker perform pain procedures at other facilities in the state.  Their Little Rock office is adjacent to our surgery center.  Due to these factors accidents can happen with where you are scheduled for future spinal injection procedures.  We want you to be aware of this possibility and if it happens we urge you to remind their scheduler of your desire for your procedures to be carried out exclusively at Legacy Surgery Center if you desire our continued concomitant care and back up in case of any need for urgent surgical care.

Why?  In the best interest of your spinal care it is our medical policy that all the patients we are caring for undergo all needed spinal procedures at Legacy Surgery Center.

Why?    All spine procedures carry a small but definite risk of complications including spinal bleeding that could possibly need emergency neurosurgery operative intervention.    If spinal procedures are done elsewhere and there is an unforeseen complication needing urgent surgery, there will be a significant delay in our ability to intervene.    This could possibly lead to irreversible paralysis that might have otherwise been avoided if not for the delay.   Also, and very importantly, when spinal procedures are performed elsewhere, we have limited ability to participate in your spinal management plan, have difficultly accessing the images from the procedures and the records of such as compared to the ease of such when done here at Legacy Surgery Center.   We believe in staying directly involved in all aspects of your spinal care to ensure the best possible quality of all of your treatment plan.  As neurological specialists we are trained in attention to detail.  We cannot achieve these goals when procedures are done on your spine elsewhere.

Therefore if you are a patient that has seen either PPS doctor at any of their clinic sites in Little Rock, Morrilton and Russellville and you are inadvertently offered or scheduled for spine procedures at one of the other outpatient surgical facilities where they work, you can and should insist that your spine procedures be performed at Legacy Surgery Center by Dr. Becker or by Legacy physicians if it is your desire that our Legacy Neurological physicians remain the “Captain” of your Spine-care-ship and be readily available for any possible emergency surgical care.

Why?   There is far more to your spine care than the actual injection of a medication with a needle into your spine.     Most pain management doctors are anesthesiologists or physical medicine rehabilitation doctors who not trained in neuro-imaging, neuro-anatomy, neuro-pathology and neuro-physiology like our Neurosurgeon and Neurologist specialists are.  PPS pain management doctors Becker and Roman are excellent at anesthesia pain management.    But they are not only not trained as surgeons of the spine, they are not surgeons of any kind.  Surgery is a field of expertise that takes 7 years of post medical school training and cannot be learned as a weekend course.   I strongly advise you to always confirm that whoever is proposing to do any form of open surgery that involves an incision and putting anything in your body other than a needle on any part of your body is in fact a trained board certified or board eligible surgeon in that field.  Nothing could be more important than confirming this for any form of spine surgery offered to you as there are pain management doctors that are performing open surgical procedures on the spine including placing spinal implants in patients after merely taking a course.  This is not the kind of training you want for your spine surgery needs!  

We strongly feel that all patient’s spine care diagnosis and plan should be created and managed by a neurological spine specialist or by spinal orthopedic surgeons regardless of who does an actual injection procedure.  We also strongly feel that whoever is your spinal surgeon should be on staff at the site where any spinal injection procedures are being performed on you regardless of who does the actual injection procedure for the reasons above – in case of a surgical emergency complication and for access to the information, records, and images for continuity of your care. 

We stay actively involved in your care all along the way with adjustments whenever necessary based on your response to various interventions starting with the least invasive plan first even if you do not initially need surgery or ever need surgery.   We are also well prepared and experienced with minimally invasive surgical options should such be necessary.

We are happy to continue to manage of your spine care if you continue to see either doctor of PPS for medication management as long as you insist that any of your spine procedures are done at our location by Dr. Becker or us for all the reasons above.  There will be no interruption of your care with these changes and apologize for any confusion this may cause.

If you instead desire to transfer your overall spine care management to PPS, we can be available at any point in the future to resume your care surgical or non surgical in the future.

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Selective Nerve Root Block

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WHAT IS A SELECTIVE NERVE ROOT BLOCK?

A selective nerve root block (SNRB) is a test performed to determine if a specific spinal nerve is the source of your arm or leg or radiating chest pain. Often patients with spine issues have multilevel MRI abnormalities often close together.   If we treat your problem with conservative care and it fails to respond, then surgery for your radiating pain may be an option. However, due to the above issue identifying which abnormality on the MRI is the cause of the actual radiating pain can be a challenge.   In most cases pain that radiates in a radicular fashion as above is caused by just one nerve root regardless of the number of abnormalities on the MRI. Therefore, we are trying, like an electrician would do in your house to find the short circuit, to isolate the responsible nerve that is the source of the pain.

A SNRB is performed to diagnose the specific nerve root of origin of your cervical (neck), thoracic (mid back) or lumbar (low back) radiculopathy (pain in the distribution of a particular nerve root off the spine due to compression, irritation and/or inflammation of a nerve root). A selective nerve root block is an injection of a local anesthetic that lasts hours to a few days very close to a specific nerve root. Along the spine, there are several exit “holes” or “foramina” through which nerve roots emerge. If these foramina are partially closed due to either bony overgrowth from degenerative changes, bulging disks, misalignment of vertebrae, etc., the nerve root can also be pinched. This typically causes a shooting or radiating pain along that nerve root. In a selective nerve root block, a small needle is placed in the foramen alongside the nerve root, and the medication is injected. The goal of a diagnostic injection is twofold. 1. We want to see if the needle adjacent to the nerve creates radiating pain that closely replicates your typical radiating pain for which you are seeking relief. 2. To see if, while the nerve that we injected adjacent to is “asleep” or effectively blocked by the local anesthetic, your normal radiating pain is gone or improved during any period of time while the block is effective. Your feedback helps to identify the cause of radiating pain.

 

WHY IS IT DONE?

When the nerves in the foramina are irritated or pinched, the resulting inflammation can cause pain, numbness, or tingling. If the local anesthetic is acting on the correct nerve that is causing the pain, then the temporary resolution of pain will provide diagnostic information to your doctor.

 

 

 

HOW LONG DOES IT TAKE TO DO?

The actual injection takes only a few minutes. Please allow about an hour for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.

WHAT MEDICINES ARE INJECTED?

The injection consists of local anesthetic that can last for a few hours to days (e.g., bupivacaine).

 

WILL IT HURT?

All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. The actual placement of the needle is not painful. However, keep in mind the nerve root is pinched and irritated. If the needle tip brushes against the nerve during placement, you may feel a “zing” down the nerve root, similar to striking your “funny bone”. During the injection of the local anesthetic, there may be a temporary shooting pain along the nerve root’s normal distribution until the local anesthetic sets in, usually in about 15 seconds. These sensations are normal and if they are very similar or identical to the pain that you normally experience then this information is very helpful in confirming the diagnosis of the “pain generator” in your case. It is very important that you let the doctor know doing the injection if you feel the typical shooting pain or not as the needle is nearing your nerve!   If the radiating pain you feel during the procedure is not in the normal distribution that you feel this is helpful information as well.   If you do not feel any radiating pain, then the needle may not have gotten close enough to the nerve. The medicine could still reach the nerve through diffusion so the block may still give diagnostic information, but we prefer to get the needle as close to a nerve as possible without injuring the nerve.

 

 

HOW IS IT DONE?

It is typically done with you lying on your stomach for thoracic or lumbar and on your back for cervical blocks. Your vital signs will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin on the back or neck is cleansed with antiseptic solution, and then the procedure is performed.

 

 

 

WHAT SHOULD I EXPECT AFTER THE INJECTION?

Immediately after the injection, you may feel your legs or arms, along that specific nerve root, becoming heavy, numb or weak. You may notice that your pain may be gone or considerably less. This is due to the effect of the local anesthetic. Your pain may return, and you may have some soreness at the injection site for a day or so. It is very important to be careful for several hours afterwards to avoid falling due to weakness if done on the lumbar or thoracic spine or dropping or mishandling things with your hand or arm if done on the cervical spine. This should resolve with the passage of hours but if it persists beyond 8 or so hours please notify our team.

 

HOW LONG DOES IT LAST?

The immediate effect is from the local anesthetic injected. This wears off at varying time intervals. It may last only 30 minutes, or it may last up to several weeks or months. The length of time that you experience relief is not as important as how much relief you experienced. Please document carefully even hourly for the first day or so.   If lucky some even get long term relief of the pain from the nerve block. Of course, that would not only be of diagnostic but therapeutic benefit!

Risks vs Benefits:

Like all procedures or tests there are risks and benefits. The benefit as above is to localize a potential target for surgery when patients have multiple possible causes. The goal here is limiting surgery to the least invasive option possible by treating only the cause of the pain not all the abnormalities on an MRI.   The risks include nerve injury, bleeding, post procedure increased pain, allergic reactions, spinal headache, infection and very rarely major neurological complications including the very rare risk of paralysis. Complications are very unlikely and most if they occur can be resolved with treatment. Nevertheless, all procedures and tests have risks.

Conclusion

Selective nerve root blocks are important to help identify the nerve root of origin of your radiating nerve pain. Although the procedure may be uncomfortable, our staff is dedicated to making you as comfortable as possible during the procedure.

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Cervical Radiculopathy

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See below for some common symptoms and treatments for cervical radiculopathy.

  • Radiating arm pain and/or numbness and tingling
  • Usually due to a ruptured or herniated disc in the cervical spine or narrowing of the exit hole for the nerve also called neural foramen stenosis
  • May be also associated with cervical spinal stenosis which can lead to spinal cord damage or cervical myelopathy
  • If not associated with spinal cord compression can be initially treated with conservative care
  • Conservative options include: Neuropathic medications, physical therapy and manipulation therapy, Cervical Epidural Injections
  • Surgery is usually via an ACDF or anterior cervical discectomy and fusion from the front of the neck for refractory cases and/or those with severe neurological issues including spinal canal stenosis.
  • When indicated surgery is usually very successful and the benefits far outweigh the risks
  • Other causes less common of this type of pain may include shoulder disease, neuropathy, CTS, brachial plexopathy, vascular disease

Images obtained via google

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Intraoperative Navigation

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What is intraoperative navigation?

Sophisticated imaging equipment that is used during surgery to provide accurate anatomical localization of important structures.

How does it help in spine surgery?

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In 2018 Legacy Spine and Neurological Specialists and Scott Schlesinger,MD proudly announce the arrival of the least invasive spinal fusion surgery option available.

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MIS spine surgery in 2018

Minimally invasive spine fusion has gotten even less invasive over the last couple of years.  I patented the MIGLIF MIS fusion surgery in the prior 2 years and still use this for many patients that need pedicle screw stabilization.  However, over the last several months, I have started utilizing a new approach that takes the MIS approach to an even greater less is more level.

This is the Vari-lift stand alone expandable inter-body fixation device.  With this I have been able to reduce the OR time to around 1.5 hours  for a extensive yet MIS neural decompression and inter-body fusion.  With this device and surgical approach offered at Legacy Spine and Neurological Specialists and Legacy Surgery Center we have had great results and very rapid recovery with much faster return to normal life than the standard open lumbar fusion surgery.

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What is causing my leg pain?

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There are many potential sources of leg pain. The nerves that provide motor and sensory function to the legs start in the lower back. These are called the lumbar nerves. Leg pain that starts in the lower back and radiates down the leg is often referred to as ‘sciatica.’

Some causes of leg pain from a lumbar spine problem include:

Disk Herniation

where the soft cushion between the bony vertebrae of the spine herniates from its normal position and causes compression of the lumbar nerves

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Numbness of the Hands

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Patients frequently complain of numbness and tingling of the hands.

The most common causes include:

    • Carpal Tunnel Syndrome (CTS)
    • Ulnar Nerve Compression
    • Spinal cord compression and other conditions of the spinal cord that cause cervical myelopathy.
    • Cervical radiculopathy
    • Peripheral neuropathy.
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What is laser spine surgery?

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Lasers have been used for many years in medicine and surgery. Their role, however, in spinal surgery is extremely limited and for good reason.

Lasers can be used to cut through soft tissues like skin and fat. This can also be done using a traditional scalpel without the risk of thermal (heat) injury to surrounding tissues and without the significant expense of using a laser.

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Smoking adds complicated risks to spinal procedures

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Many surgeons, especially neurosurgeons, urge patients to stop smoking before spinal procedures, particularly, spinal fusions.

Why?

An extensive amount of research has found that smoking cigarettes prolongs the healing process and causes complications. Below is a list of problems that can arise:

  • Decreased rate of successful fusion (called non-union or pseudoarthroses)
  • Poorer clinical outcomes, including pain reduction
  • Poor rehabilitation after surgery, and prolonged healing process
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Is your bulging disk causing your back pain?

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As our bodies age so do our spines. Arthritic changes will be present in the spine which include bulging disks, degenerative disk disease and joint changes. The degree that these changes occur are often related to genetics. A simple bulging disk is actually an extremely common finding on MRIs of the spine and is not an indication for surgery. There are many other structures in the low back and neck that are very sensitive to pain especially the muscles and numerous joints that support the spine. These are more often the cause of low back and neck pain and are treated with conservative therapies. Occasionally a disk will actually herniate out of the normal position between the vertebral bones and cause pressure on spinal nerve resulting in extremity pain. The disk herniation itself is not painful but can result in pain by causing inflammation and/or pressure on these spinal nerves. If extremity pain from a compressive herniated disk cannot be fixed with conservative treatments sometimes surgery is indicated. Our neurosurgeons are trained to read spine MRIs, understand the complicated anatomy of the spine and perform neurological exams to determine appropriate treatment options. 

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