Professor Arun Ranganathan, one of the leading spinal surgeons in the UK, has operated on many high-profile patients, from royal family members to fellow spine and orthopaedic surgeons and is referred to as ‘the surgeon’s surgeon’. Here, he shares his thoughts on the current developments in spinal surgery and future concepts.
As an ageing population, more patients are requiring interventions to manage back and neck pain. Mostly this is a benign mechanical or muscular dysfunction, but can occasionally be a result of a more serious condition such as a deformity, tumour or infection.
Spinal surgery is supported by many other medical specialities and ancillary treatments, concentrating their attention on the mobility of the spine and reducing the number of surgical candidates. When faced with a definite, and sometimes urgent need for surgery, the surgeon has a number of factors to consider.
Rapid recovery spine surgery
Sciatica is a prolapsed disc pressing on the nerve causing shooting pain radiating from the back into the leg, that can often be debilitating. The pain often settles down within a few weeks but sometimes it can be non-responsive to analgesics leading to weakness in the foot. If this is the case, we would usually treat with a steroid injection in the back. This is a quick procedure and often reduces the neural inflammation enough to alleviate any pain or numbness. If the prolapse is too large or the steroid injections aren’t effective, surgery may be the only option, but with minimal access surgical techniques and equipment, it is now possible to do this surgery as a day case through a very small incision. This surgery allows the patient to return to normal activities and work very quickly as the muscles are preserved.
This latest technology allows surgeons to perform more complicated surgery such as tumour removal as key-hole surgery, allowing patients to leave the hospital within 24 hours, with excellent clinical outcomes. They often return to work within a week and generally sport is possible within a month.
This is a sharp contrast to open surgery where patients have restricted mobility for more than six weeks and extensive loss of musculature as a result of surgical scarring and require intense physiotherapy and rehabilitation.
Patient Story – The unexpected can happen
On the 1 March I had the first major operation in my life, aged 58. Medically it was an excision of intradural lesion, left L4/5 decompression by keyhole surgery. To me, it was a remedy to having extreme pain down my left leg and backside, which had stopped me even being able to sit down for more than a few minutes. This had developed over quite a short period of six to eight weeks. Professor Ranganathan performed the operation two days after I first met him and got me home the day after the operation, as promised. I thought I had done well just being able to walk the distance of the ward without any pain on the day of the surgery. So, on 1 September, I set out on a run (I had been running for a few months by now) and two hours 56 minutes later, I had completed a half marathon. Now that really impressed me. That is the fastest I had run in at least five, perhaps 10 years.
Muscle sparring scoliosis surgery
Scoliosis surgery is usually an open procedure requiring the surgeon to cut through the muscle and leaves a long scar meaning a longer recovery for the patient. This is life-changing surgery for the patients, and it is an honour as surgeons for us to help patients as we do.
Minimally invasive scoliosis surgery can decrease the recovery time and the amount of muscle that is cut through. It is a difficult procedure due to the length of the rod and lack of visibility, but done well, the results are outstanding and lead to the patient returning to normal activities a lot sooner and with less physiotherapy and rehabilitation. Controversies in this technique relate to fusion rates and inability to perform bony releases to aid correction.
Tackling difficult surgery
Severe adolescent isthmic spondylolisthesis (SAIS) is a condition that requires surgical intervention and there are different opinions on the ideal surgery to undertake – should the young patient’s spine be left in-situ or should the surgeon undertake a stabilisation and reduction. Using minimal access techniques, with key hole surgery, we reduced a high grade spondylolisthesis completely. The X-rays and scans on the right show a grade 4 spondylolisthesis in a 15-year-old patient. This has been reduced using minimal access techniques entirely using a posterior approach.
Spinal deformity – Scoliosis and technology
Scoliosis is often viewed as difficult surgery due to the altered anatomy that one would normally see in the spine and the surgeons performing this surgery have trained specifically to place screws in a rotated spine and correct spinal deformities. This is high-risk surgery due to the different anatomical features and the stresses put on the spinal cord while correcting the deformity. There are few spinal surgeons who specialise in this field, given the high risks involved and the long learning curve. Scoliosis surgery is undertaken in only a few centres across the UK and it is mainly a procedure performed in children and adolescents.
New technologies have emerged that make screw placement easier, but this may come at a cost, with the reliance on technology reducing the skill of the surgeon and increasing the radiation exposure to the patient. The development of robotics is ongoing, and it is hoped to include correction of spinal deformities, such as scoliosis, in the future. The current technology relies on X-ray images meaning increased radiation exposure. Although this works well in conditions such as fractures and spinal fusions, there is little evidence that robotic systems are comparable to a skilled surgeon in scoliosis – they only focus on part of the operation and are unable to consider other factors such as 360-degree alignment and rotational correction. These technologies can also increase the surgical time and require more personnel and equipment in the operating room – all of which increase the risk of infection.
In the UK, we have a well-established healthcare system that identifies and treats patients with spinal deformity, but other countries are not as fortunate, and it is only when the condition is very severe do the patients seek help. These severe spinal curvatures sometimes benefit from special equipment which help with screw placement and also to radiologically study the spine during the operation. This is offered by computerised systems called navigation that assist the surgeon in safely placing a screw into the bone. We have been fortunate to train local staff and perform surgery on some incredible and difficult anatomies when working in both Vietnam and India.
New technologies to ‘help the body heal itself’
There is a lot of interest and discussion surrounding stem cells and regenerative medicine, with research ongoing into the use of regenerative medicine and stem cells in spinal surgery. It is early days, but also exciting to see what this may mean for arthritis and the spine. Professor Ranganathan was at the fore of research into nutrition of lumbar discs and this was a significant step towards regenerative medicine and a role in spine biology. In 2009, his research centred on predicting which lumbar discs will degenerate in the future and how external factors affect this degeneration. Prof. Ranganathan is the first and only UK surgeon to have been awarded the prestigious ISSLS Prize twice for this research work.
Future of spinal surgery – Robotics, virtual reality with haptics and artificial intelligence
Augmented Reality (AR) headsets are also showing great promise in allowing X-ray, CT and MRI images to be overlaid on top of the actual surgical field. By overlaying other images in the surgical field of view, surgeons will be able to see the structures they need to avoid such as the spinal cord and major blood vessels. This is already being used in some surgical cases through a microscope but not before using a VR headset. In the near future artificial Intelligence has the capability to develop scenarios for enhanced surgical training experience.
The application of VR and haptics in the medical training field aids in reducing negative implications of the traditional training methods, especially reducing patient risk. VR and haptics-based simulators provides a safe environment for medical trainees to develop their skills to a certified level even before coming into contact with actual patients.
We believe technology has the ability to enhance our skills and reduce the learning curve when in training or when trying a new device, instrument or technique. The caveat is that we consider the speed at which we adopt these innovations and don’t rush headfast into technology because it is new and exciting. That said, it is without doubt that the integration of technology has the potential to increase the scope of modern-day spinal surgery.
