Maintaining a healthy back is very important. Modern life, however, puts a lot of wear and tear on the back, and when degenerative disc disease is present, surgery can relieve back pain. With an aging population, this is especially true. As Baby Boomers and Generation X get older, the number of back fusion surgeries is increasing. According to Orthopedic Design and Technology websiteThe global spinal fusion market is growing 4.4% per year, with an average of 400,000 procedures per year in the United States.
With the growth of the market and the new technologies in play, spinal fusion surgery is also changing. John Klekamp, MD, an orthopedic surgeon at the Tennessee Bone and Joint Institute who specializes in spinal care, performs two to three spinal fusion surgeries per week using the newest technology and procedures. He prefers a technique called lateral oblique interbody fusion.
“This is a different approach to spinal surgery,” explained Dr. Klekamp. “The surgery is actually called Lateral Lumbar Interbody Fusion. It uses a corridor on the patient’s flank to access the spine for surgery. Unlike the traditional approach, which everyone thinks of as the scar on the back, it involves a pelvic incision on the patient’s left flank in line with the armpit and hip. We use X-rays and specialized retractors to divide the musculature on the side of the abdomen to get to the front of the spine for surgery where we have access to the entire lower back.”
For a long time, traditional lower back surgery has meant an incision in the middle of the back, which requires going through the back muscles, dividing them, and retracting them. Since these are some of the largest muscles in the body, subsequent surgery can mean a lot of pain and a more difficult recovery. This older approach also means going directly to the nerves, using special tools to decompress the nerves away from the back bones. While this technique has worked well for over 100 years, and continues to work, lateral lumbar interbody fusion is less invasive and offers a quicker recovery time.
“Now we have developed two lateral approaches, the direct lateral approach and the oblique lateral approach,” Klekamp said. “I prefer the oblique.”
When accessing the vertebra from the left side, indirect nerve compression occurs; which means less chance of nerve injury, less chance of scar tissue forming around the nerves, and less chance of cerebrospinal fluid leak or tearing of the dura.
Indirect spinal access also increases the space where the doctor removes the damaged disc and then replaces it with a fusion cage or interbody device. These devices are made of PEEK, which is a form of plastic, or titanium. Dr. Klekamp prefers titanium and also uses a small titanium plate to hold the case in place and support the back. A bone is placed inside the cage and will fuse through the cage over time after the operation. That can take three to six months.
The benefits of this approach are that it is minimally invasive, less painful, carries less risk of infection, and a faster recovery process. Recovery is usually one or two nights in the hospital, depending on the amount of dissection. How long you stay in the hospital also depends on the amount of pain in your hip psoas muscle, since much of the operation occurs around this muscle.
“We keep patients overnight to make sure the pain goes away and they can walk,” Dr. Klekamp noted. “They may still have a slight limp for less than a week.”
Lifting is limited to five to 10 pounds for the first six weeks of healing time after surgery before increasing to 25 to 30 pounds for another six weeks after the procedure. Patients see the doctor every two to three months for X-rays to evaluate the fusion process. In addition, the activities of the patients are restricted until fusion through the cage has occurred. Once that occurs, there is no restriction to activity. Very little physical therapy is performed other than walking on their own, as fusions occur faster when there is less movement around the graft site.
“Once the fusion is complete, the prognosis is excellent,” said Dr. Klekamp. “[Patients] they have only a 10-15% chance of developing problems above or below where we merged. Because that disc is gone and is now fused, your body will put pressure on the adjacent discs. [possibly] causing adjacent segment disc degeneration within 10 years of a fusion.”
By definition of fusion, there will be no movement left in the operative disc space. However, there are many other discs throughout the thoracic and lumbar spine that would help compensate for the lack of movement of the fused disc. Patients rarely describe a loss of range of motion after surgery.
Degenerative disc disease is the number one reason to undergo lumbar surgery with the average age of sitting patients being 55 years old. While a variety of factors can come into play, this disease is often genetic, and research shows that it runs in families. Sometimes it is caused by previous trauma, and obesity can also play a role.
Dr. Klekamp earned his medical degree from Mercer University School of Medicine in Macon, Georgia. He began his residency training in internal medicine and completed his training in orthopedic surgery at Vanderbilt University Medical Center. He completed his fellowship in spine training at the Emory Spine Center in Atlanta, Georgia. Prior to joining Franklin Bone and Joint in 2004, Dr. Klekamp practiced with Piedmont Orthopedics in Greenville, South Carolina, where he managed the spine residency training program for Greenville Memorial Hospital and later served as adjunct instructor in Biomechanical Engineering. from Clemson University. His professional interests include various approaches and treatments of the cervical spine, including anterior cervical discectomy, anterior cervical disc arthroplasty, lumbar decompression, and minimally invasive cervical decompression. He is Zimmer/Biomet certified for surgery using the Mobi-C Cervical Disc Arthroplasty System. Dr. Klekamp is a member of the American Academy of Orthopedic Surgeons (AAOS) and the North American Spine Society.
For more information on lumbar surgery, contact Dr. John Klekamp of the Bone and Joint Institute of Tennessee. Dr. Kelkamp can be reached at (615) 791-2630. EITHER schedule an appointment online.
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