Complex Spine Surgery
Spine surgery is widely regarded as challenging and prone to complications.
One of the most well-known spinal procedures is discectomy—the surgical removal of a herniated intervertebral disc from the spinal canal or nerve root canal. Decompression of a narrowed spinal canal is another commonly performed spinal operation. In experienced hands, these procedures are generally straightforward and safe.
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However, when spinal stability - and consequently the function of the spinal cord or nerve roots - is at risk, stabilization and fusion techniques become necessary. In such cases, spinal implants are used. These operations tend to be more complex, and complications occur more frequently.
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But what exactly is complex spine surgery? There is no universally accepted definition, but it typically involves realignment of the spine, requiring sometimes long fusion constructs, bony resections (osteotomies), and other specialized techniques and surgical approaches. A prime example of complex spine surgery is modern spinal deformity correction. Of course, severe spinal trauma, tumors, and challenging infections - among other conditions - may also require complex surgical intervention.
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On this page, I present an example of an adult spinal deformity patient and her surgical treatment. The patient underwent the procedure several years ago and she kindly granted permission to use the images.
The patient was unable to stand upright. She leaned forward and to the right, indicating a loss of both sagittal and coronal balance. To maintain a standing posture, she had to overuse her posterior muscles far beyond normal capacity. After just a few minutes, these muscles could no longer counteract gravity, forcing her to sit or lie down - a typical clinical appearance of spinal imbalance.
The standing X-rays of the same patient. On the left, the typical kyphosis of the apex regions of the thoracic and lumbar curve causing a disturbed saggital balance. On the right, over 80 degrees thoracic and lumbar curves in the PA-image.
Decision for the surgical treatment
Over the years, the patient underwent various conservative treatment plans, but unfortunately without success. In cases of adult spinal deformity, scientific studies have demonstrated that conservative treatment is generally less effective than surgical intervention, which consequently became a viable option for this patient as well.
It is clear that correcting this deformity requires major, complex spine surgery. After careful preparation, consultations, and meticulous planning, a combined anterior (abdominal) disc space release with lordosing, and posterior (back) pedicle screw assisted correction and fusion from T4 to the ileum was performed in a single surgical session. The total operative time was approximately nine hours, including patient repositioning, setup of the intraoperative neuromonitoring system and 3D imaging for the computer assisted navigation.
While complications are possible, our team is fully prepared to manage them
Despite antithrombotic medication and pneumatic leg pumps, the patient developed an acute deep venous thrombosis in the left common iliac vein, which was successfully treated with intravenous catheter aspiration and stenting one week after the operation. Four years later, she developed a late hematogenous deep infection that required one-time surgical debridement, replacement of the posterior implantation, and a three-month course of antibiotic treatment. The infection subsequently resolved uneventful.
What about the result?
Below are clinical photographs and X-rays taken approximately five years after the operation. Clinically, her standing balance appears normal, and overall body symmetry is satisfactory. She reports no back pain and is able to walk several kilometres. In winter, she even enjoys cross-country skiing. As expected, her back is stiff, and she is unable to reach her feet, making the use of a sock aid necessary.
The X-rays show a well corrected, proportioned spinal alignement. You can see three anterior screws used to secure the three intervertebral cages, which are made of PEEK (polyetheretherketone - a radiolucent material not visible on standard X-rays). Additionally, cement augmentation of the proximal junction can be observed in vertebrae T3, T4, and T5. This procedure was performed to reduce the risk of proximal junctional kyphosis and failure.
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Over the years, my correction techniques have remained largely consistent; however, I now use titanium cages, as shown in the X-ray on the front page. Additionally, I have reduced the use of cement augmentation, as clinical studies have not shown it to be significantly effective in preventing proximal junctional complications.
