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Changing patterns of spine surgery

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Neurosurgery
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commentary
complex spine surgery
discectomy
endoscope
endoscopic microdiscectomy
herniated disc
laminectomy
minimally invasive spine surgery
 
Herniated disc surgery is the "bread and butter" for spine surgeons, but might not remain so. In the developed world, populations are rapidly aging, comorbidities are changing and the number of spine surgeons is shrinking.
 
Herniated disc
A herniated or slipped disc is where one of the discs in the spine ruptures and the gel inside leaks (herniates) and causes back pain and sciatica. Once the nucleus herniates, pain in the lower back may improve, but sciatic leg pain increases. This is because the jelly-like material puts pressure on spinal nerves, which causes pain, numbness, or weakness in one or both legs.
 
Incidence
Most cases of herniated discs are age related and presented in men between 30 and 50. Fifty six per cent of adults have bulging discs, 80% of these will experience back pain, but only two to three per cent will have sciatica. Males present with back pain about 10 years before females. The mean onset of back pain is 35 and it's unusual in people under 20 and over 60.
 
Most people with a herniated disc don't require surgery because their symptoms improve over time. About 50% recover naturally within about four weeks.  Within six months, 96% recover. Only 10% have surgery. 
 
Nonsurgical treatments
Physical therapy and analgesics are the most common therapy for spinal problems. Maintaining spinal strength and flexibility through exercise is important. Passive manipulation may have a role, but it's not a substitute for strengthening the muscles.
 
Nerve pain, such as sciatica, usually does not respond well to physical therapy and is therefore often treated by an epidural. This is an image guided spinal procedure performed as a day-case using fine needles and probes, which are inserted through the skin and guided by continuous X-Ray or CT screening directly to the site of the suspected problem. 
 
Surgical treatments
Surgical therapy is typically recommended when symptoms have not improved using other treatments and the patient has difficulty standing or walking and there is progressive muscle weakness or altered bladder function. 
 
The most common surgical procedure for a herniated disk in the lower back is a lumbar micro discectomy, which involves removing the herniated part of the disk and any fragments that are putting pressure on the spinal nerve. Endoscopic micro discectomies are increasing, but still relatively new and often only performed with special arrangements, such as being part of a clinical study.

An early adopter
Mr Irfan Malik, a consultant neurosurgeon at Kings College Hospital, London is an experienced early adopter of endoscopic micro discectomy for a herniated disc. 
 
According to Mr Malik, "The procedure only takes about an hour. After the endoscope is removed, a plaster is used to cover the small incision. After the procedure, most patients walk away and go home within a couple of hours. While the success rate of this procedure is about the same as conventional open back surgery, recovery rates are quicker and risks of complications much lower".
Changing Spine surgery
Over the next 20 years, as populations' age, spine surgeons will be challenged to address a different mix of diagnoses and additional comorbidities; such as lumbar spinal stenosis and spondylolisthesis.
 
Nearly 25% of people over 65 suffer low back pain.  In the US alone this translates into over seven million doctor visits annually.  Over the next decade, degenerative spinal conditions are projected to significantly increase pressure on hospitals and primary care offices.  
 
More of these older patients however, are expected to have access to advanced spine care and minimally invasive techniques.  According to Mr. Malik, "Research is driving advances in surgical techniques as well as new devices and tools, which will expand the treatment options for patients."
 
Takeaways
Health providers are beginning to look for new ways to combat the combined challenges of aging populations, shifting comorbidities and projected shortages of doctors. Training is encouraged in surgical specialities where there are shortages and nurses are being trained to conduct initial patient visits.

Increasingly, patients are given e-mail access to clinics to determine treatments, computer portals are being used to streamline the entry process to clinics and video explanations of surgical procedures and teir risks are being developed specifically for patients.
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