At Home Christian Jessen 2014 - 139

| PROMOTION|
spinal surgeon, Mr Shaun Ridgeway. 'The surgery
in my practice is for patients for whom
conservative management has not worked. This
includes at least six months of exercise-based
physical rehabilitation and pain management.
Their pain, muscle spasms and other symptoms
are significant and make it difficult to function
normally during daily activities, work and in
relationships, despite ongoing pain management.
'It is important for patients to understand that
no irreversible damage will occur, preventing
surgery in the future, if further attempts at
conservative treatment are commenced. These
surgical procedures are major and have risks;
they often never resolve, but do improve, pain,
function and activity, giving most patients
a period of five to seven years of significant
improvement compared to the conservative
long-term approach. Lumbar back pain is
complex and, often, there are multiple possible
pathologies identified on scans that may
account for pain, making the diagnosis and
treatment very difficult. It is important for patients
to understand that there is often no correlation
between how badly a disc may have features
of degenerative changes on a scan, and the
intensity of pain experienced and vice versa.
'Patients should be aware that investigations
/scans help identify the problem and potential
treatment, however it is the patient and their
symptoms that describe whether surgery is
indicated. (Fig 1) There are two main types
of surgery to treat lumbar degenerative discs
causing pain: Lumbar Fusion Surgery and
Lumbar Disc Replacement Surgery.'

Artificial Disc Replacement
Surgery (ADR)

ADR surgery requires an anterior approach
through the abdomen, behind the stomach
muscles, moving bowel and blood vessels out
of the path. 'This has been performed for many
years,' says Mr Ridgeway. 'It tends to have the
best results in early L4/5 disc degenerative
disc disease, without facet joint problems or
malalignment, in patients who have not had
previous surgery to that level. The aim is to allow
movement at the level treated and potentially

Fig 1: MRI scan showing
a degenerative L5/S1 disc

avoid degeneration at adjacent level above
or below. If pain develops in the future at this
level from facet joint degeneration, then this
may be converted to a fusion.'

Lumbar Fusion Surgery

Fusion Surgery is more common. 'The aim of
fusion surgery is to stop movement at a painful
motion segment by adding bone graft, joining
the vertebrae on either side of the painful disc,
forming a single bone mass, thus eliminating
motion that is thought to cause the pain,' Mr
Ridgeway explains. 'This cannot be reversed.
There are many approaches to fusion surgery.'
Each procedure has its own risks, benefits
and fusion rates, all of which should be
discussed with patients. Bone graft may be
taken from the patient's own bone (autograft),
harvested from cadaver bone (allograft) or
manufactured (synthetic bone graft substitutes).
The most commonly used surgical techniques
nowadays include the following:
POSTERIOR INSTRUMENTED FUSION Using
screws, rods and bone graft from the back.
POSTERIOR LUMBAR INTERBODY FUSION
(PLIF) As above, but the disc is removed and
cages/spacers (usually two) are inserted with
bone graft into the disc space.
TRANSFORAMINAL LUMBAR INTERBODY
FUSION (TLIF) This is the same as a PLIF but the
approach is oblique, from the back, usually with
a single cage and commonly used in Minimally
Invasive Spinal (MIS) surgery techniques (Fig 2).
ANTERIOR LUMBAR INTERBODY FUSION
(ALIF) The disc is approached from the front,
similar to Artificial Disc Replacement (ADR).
EXTREME LATERAL INTERBODY FUSION
(XLIF) The disc is approached from the patient's
side through muscle-splitting.
ANTERIOR/POSTERIOR FUSIONS
A combination of anterior or lateral cage
insertion and posterior screw insertion via two
separate incisions/approaches, often at two
different times.

Complications

The risks vary according to the individual
patient, surgical approach, levels involved

Fig 2: Radiographs following
a minimally invasive L5/S1
Transforaminal Lumbar
Interbody Fusion (TLIF) with
screws, rods and titanium
cage within the disc, holding
bone graft material

Fig 3: Scars from a minimally
invasive spinal fusion with
Transforaminal Lumbar
Interbody Fusion (TLIF)
technique

MEET THE
EXPERT

Consultant Spinal
Surgeon, Mr Shaun
Ridgeway (pictured,
left) BM FRCS Ed
FRCS (Tr&Orth)
A consultant spinal orthopaedic surgeon
since 2009, Mr Ridgeway qualified from
The University of Cape Town in 1997.
His orthopaedic training took place
in London with specialist and fellowship
training in spinal surgery at The Royal
National Orthopaedic Hospital,
Stanmore. He is a member of the British
Association of Spinal Surgeons (BASS).
Mr Ridgeway has experience in all
aspects of spinal surgery. His specialist
interests include spinal surgery,
degenerative spinal surgery, minimally
invasive surgery, cervical surgery, adult
deformity surgery, kyphoplasty,
vertebroplasty, and spinal trauma.
Mr Ridgeway offers his services at BMI
Hospitals, including BMI The Princess
Margaret Hospital, BMI Clementine
Churchill Hospital and BMI Bishops
Wood Hospital NHS. Choose and book
at BMI The Princess Margaret and
Clementine Churchill Hospitals.

and complexity, and should be discussed
in detail with the patient prior to the informed,
signed consent for a surgical procedure.
These include: anaesthetic and medical risks,
infections, bleeding, misplaced screws requiring
further surgery and repositioning, failure
of fusion, nerve injury and weakness; and
ongoing pain without a clear cause identified
despite a successful fusion. Depending on the
level, about 20-30% patients will develop
degenerative problems at the adjacent level.

Minimally Invasive Surgery
(MIS) Techniques

Often, a procedure may be performed via this
approach. The aim is to preserve the muscles,
through less muscle dissection than traditional
open techniques; via specific techniques, with
specially developed instrumentation (Fig 3).
This requires specific training and experience.
The goal is still to achieve a fusion and the
results should be the same as open techniques.
These approaches offer quicker recovery
periods; less blood loss, reduced pain and
hospital stay, but generally the long-term results
at one year are the same as open techniques.

FOR MORE INFORMATION
Contact Carol Wollington,
PA to Mr Ridgeway.
Call 020 8872 3959 or 07546 364491.
Fax 020 8150 5625.
Email carol.wollington@bmihealthcare.co.uk



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