Maintaining a healthy back is very important. Modern life, however, causes a lot of wear and tear on our backs and when there is degenerative disc disease, surgery can ease back pain. With an aging population, this is especially true. As Baby Boomers and Generation X get older, the number of back fusion surgeries are increasing. According to Orthopedic Design and Technology’s website, the global spinal fusion market is growing by 4.4% per year, averaging 400,000 procedures per year in the United States.
With the growth of the market and new technologies in play, spinal fusion surgery is changing, too. John Klekamp, M.D., an orthopaedic surgeon of Bone and Joint Institute of Tennessee who specializes in spine care, does two to three spinal fusion surgeries per week using the newest technology and procedures. He prefers a technique called Oblique Lateral Interbody Fusion.
“This is a different approach to surgery on the spine,” explained Dr. Klekamp. “The surgery is actually called a Lateral Lumbar Interbody Fusion. It uses a corridor on the patient’s flank to access the spine for surgery. Different from the traditional approach, which everyone thinks of as the scar on the back, this is an incision of the pelvis on the patient’s left flank in line with the arm pit and the hip. We use X-ray and specialized retractors to divide the musculature on the side of the abdomen to get to the front part of the spine for surgery where we have access to the entire lumbar region.”
Traditional lower back surgery has long meant an incision in the middle of the back, requiring going through the muscles in the back, dividing them and retracting them. Since these are some of the largest muscles in the body, post operation can mean a lot of pain and a more difficult recovery. This older approach also means going directly at nerves, employing special tools to decompress the nerves away from the back bones. While this technique has worked well for more than 100 years – and continues to work – Lateral Lumbar Interbody Fusion is less invasive and offers a quicker recovery time.
“We have now developed two lateral approaches, the Direct Lateral Approach and the Oblique Lateral Approach,” said Klekamp. “I prefer the Oblique.”
By accessing the vertebra from the left side, there is indirect nerve compression; meaning less chance of nerve injury, less chance of scar tissue forming around the nerves, and less chance of a spinal fluid leak or Dural tear.
Indirect access to the spine also increases the space where the doctor is removing the damaged disk and then replacing it with a fusion cage or interbody device. These devices are made of either P.E.E.K., which is a form of plastic, or titanium. Dr. Klekamp prefers titanium and also employs a small titanium plate to hold the cage in place to support the back. Within the cage is placed a bone that will fuse through the cage over time following the operation. That can take three to six months.
Benefits from this approach are that it’s minimally invasive, less painful, comes with 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. Time spent in the hospital also depends on the amount of soreness in the psoas muscle in the hip, since much of the operation occurs around this muscle.
“We keep patients overnight to make sure that soreness goes away and they are able to walk,” noted Dr. Klekamp. “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 the surgery before being increased to 25 to 30 pounds for another six weeks after the procedure. Patients see the doctor at two to three month intervals to get X-rays to evaluate the fusion process. Also, patients’ activities are restricted until fusion has taken place through the cage. Once that occurs, there is no restriction to activity. Very little physical therapy takes place other than the patient walking on their own, as fusions occur faster when there is less motion around the grafting site.
“Once the fusion is complete, the prognosis is excellent,” said Dr. Klekamp. “[Patients] have only a 10% to 15% chance of developing issues above or below where we do the fusion. Because that disc is now gone, and it is now fused, your body will put stress on the adjacent discs [possibly] causing adjacent segment disc degeneration within 10 years of a fusion.”
By definition of fusion there will be no motion remaining in the operative disc space. However, there are multiple other discs throughout the thoracic and lumbar spine that would assist in compensating for the lack of motion of the fused disc. Patients rarely describe a loss of range of motion following surgery.
Degenerative disc disease is the number one reason for having lumbar surgery with the average age of patients sitting right at 55 years old. While a variety of factors can come into play, this disease is often genetic, with research showing it runs in families. Sometimes it is caused by a previous trauma, and obesity can also play a role.
Dr. Klekamp earned his medical degree from the Mercer University School of Medicine in Macon, Georgia. He began his residency training in internal medicine and completed orthopaedic surgery training at Vanderbilt University Medical Center. He completed his spine fellowship training at the Emory Spine Center in Atlanta, Georgia. Prior to joining Franklin Bone and Joint in 2004, Dr. Klekamp practiced with Piedmont Orthopaedics in Greenville, South Carolina, where he managed the spine residency training program for Greenville Memorial Hospital and later served as an adjunct instructor with Clemson University’s Biomechanical Engineering. His professional interests include various approaches and treatments of the cervical spine, including cervical anterior discectomy, cervical anterior disc arthroplasty, lumbar decompression and minimally-invasive cervical decompression. He has a certification by Zimmer/Biomet for surgery using the Mobi-C cervical disc arthroplasty system. Dr. Klekamp is a member of the American Academy of Orthopaedic Surgeons (AAOS) and the North American Spine Society.
To learn more about lumbar surgery, contact Dr. John Klekamp of Bone and Joint Institute of Tennessee. Dr. Kelkamp can be reached at (615) 791-2630. Or schedule an appointment online.
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