Image-Guided Spine Surgery Revolutionizes Visualization
An Interview with Artem Y. Vaynman, MD Neurosurgeon NYU Winthrop Hospital
Viewing the intricate, multifaceted anatomy of the spine during surgery has always been challenging. However, with the development of microsurgery, advanced imaging technology and — most recently — image-guided spine surgery, visualization of the complex structure has reached new heights.
Now, instead being restricted to traditional invasive spine surgery — where only the part of the anatomy that is exposed can be seen — spine surgeons have more treatment options to offer select patients. Because they can obtain a full view of the spine with the new visualization technology, they can perform less invasive, safer surgery percutaneously, through small incisions.
A 70-year-old man with a history of laminectomy using instrumentation and fusion, was experiencing uncontrollable back and leg pain that was worsening steadily and preventing him from walking or standing for more than 30 seconds.
Artem Vaynman, MD, a Board-Certified neurosurgeon, recently employed image-guided surgery to treat this patient, who was diagnosed with postlaminectomy syndrome at L3-L4 and L4-L5. He also had residual stenosis at that site and developmental stenosis at L2-L3, as well as bilateral radiculopathy and instability.
“After his first surgery at another institution seven years earlier, the patient never improved,” reported Dr. Vaynman, who specializes in complex and minimally invasive spine surgery, “When he presented recently, he was in severe pain, had great difficulty walking, and his symptoms were growing progressively worse, reducing his independence substantially.”
Revision spinal surgery carries additional risks, including poor healing, increased incidence of wound infections and cerebrospinal fluid leaks. Since this patient needed decompression of his nerve roots, fusion would be necessary to re-establish spinal alignment and stability. This made him an ideal candidate for a combination of minimally invasive and open surgery.
Dr. Vaynman recommended a complex two-stage surgical procedure: Stage one consisted of a minimally invasive anterolateral diskectomy with interbody fusion from L2-L3 and L3-L4. The second stage comprised revision of the L3- L4 and L4-L5 laminectomy, and an L2-L3 laminectory with bilateral facetectomy and foraminotomy, as well as L4-L5 diskectomy with interbody fusion.
Image-guided technology includes an infrared navigation camera that tracks the movement and position of Smart instruments with LEDs in the surgical field. However, at its core is specialized computer software that correlates pre- operative CT scans with intraoperative anatomy, providing the surgeon with real-time guidance during the operation when visibility with the human eye is problematic.
First, the patient’s CT scan was downloaded into the surgical navigation computer, which converted the 2-D images into a virtual 3-D model of his unique spinal anatomy. Then, on the day of the surgery, he was fitted with a special probe carrying the LEDs. A camera, hooked to the computer, tracked the LEDs as Dr. Vaynman moved.
During the operation, image registration matched pre-defined points on the computer model to the patient’s real-time anatomy, creating a digital road map of the spine, and enabling Dr. Vaynman to avoid potential damage to surrounding tissue and structures. The surgery was successful and the recovery uneventful. Two days postoperatively, the patient had only incisional pain, which was controlled with small doses of pain medication. He no longer felt the pre-operative pain and was walking without difficulty.
“In the past, such complicated procedures were extraordinarily long and would necessitate taking multiple X-ray images to guide us and verify the location of instruments, placement of implants and alignment,” Dr. Vaynman explained. “Today, we can work with unprecedented precision, safety and accuracy without exposure to radiation or the need for open surgery. Additionally, in spinal fusion, image- guided surgery helps us plan the position, length and diameter of the pedicle screws, and then plant instruments exactly as planned.”
Image-guided surgery not only enhances visibility, reduces use of radiation in the OR and shortens the length of the procedure, it also allows for a speedier recovery, and provides immediate quality control, as well as the ability to check progress before concluding the operation.