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Surgical Treatment Methods and Surgery Statistics

Lumbar Disc Herniation

An intervertebral disc lies between adjacent vertebrae in the vertebral column. Each disc reduces impact on the body trunk as padding. (Fig.1) A strong impact on a disc or loss of disc’s resilience due to aging causes its structure to rupture. As a result, the internal content of the disc is pushed out and protrudes. This phenomenon is called Intervertebral Disc Herniation. (Fig.2When a disc protrudes toward the back (in the direction of the spinal canal) and compresses nerves, it causes not only lower back pain but also dull pain in the lower extremities. When symptoms progress to impaired mobility, loss of strength in the lower extremities makes patients vulnerable to stumbling. If severe compression of nerves due to herniation damages a nerve called the cauda equina, it may result in problems with urinating and passing stools. Symptoms like pain and numbness often intensify when bending forward or being seated. As intervertebral discs and nerves cannot be depicted radiologically, MRI exams play a central role for identification of the disease.

It is crucial to see a Specialist in Spine and Spinal Cord Injury for a diagnosis and treatment of Intervertebral Disc Herniation, as in some rare cases, a disc may be extruded further out. When pain in the lower extremities persists despite of an appropriate medical treatment, paralysis of the lower extremities becomes worse and worse, or problems with urinating and passing stools as mentioned above come up, surgical treatment is vital for your health. Surgical treatments include Micro Endoscopic Discectomy (MED) (Fig.3), Microsurgical Discectomy, or Laser Therapy. However, types of herniation treatable with Laser Therapy are limited. Please consult our specialists.

Fig.1Click to enlarge
Fig.2Click to enlarge
Fig.3Click to enlarge

Spondylolysis/Spondylolisthesis

Spondylolysis is a defect in the connection between vertebrae that should be connected by facet joints of the vertebrae. This separation of the pars interarticularis often occurs at the fifth lumbar vertebra and mostly among children at school age when participation in sporting activities. For that reason, a stress fracture is suspected due to repetitive external impact on the lumbar region. Although the main symptom is lower back pain, very often the pain comes only during physical activities but is not much felt during ordinary daily activities. Under this situation, it is often left untreated. When it is treated with a conservative method, such as immobilizing with a corset or a casting at an early stage, fractured parts highly likely fuse properly. For a diagnosis at an early stage, not only an X-ray exam but CT and MRI exams are important. It is critical to see a specialist physician at an early stage when your child complains lower back pain during sporting activities.
When spondylolysis is left untreated, stability gets lost between vertebrae sitting on top of each other, which may cause vertebral malalignment. This is called Spondylolytic Spondylolisthesis. The disease is considered to be more commonly seen among young people whose bone growth is insufficient. In case of severe Spondylolisthesis, dull pain or numbness begins in the lower extremities and a surgical treatment is required. Therefore, an accurate diagnosis and proper treatment at an early stage are crucial. When lower back pain persists or pain or numbness in the lower extremities is recognized, it is recommended to consult a Specialist in Spine and Spinal Cord Injury without delay.

Lumbar Spinal Canal Stenosis

In the backbone, there is a passage for nerves called spinal canal, which is the space in the posterior part of vertebral column and adjoins intervertebral discs. After long years of supporting body’s weight, the backbone degenerates narrowing the spinal canal. (Fig.4) A narrowed spinal canal in the lumbar region is called Lumbar Spinal Canal Stenosis. In fact, the number of Lumbar Spinal Canal Stenosis patients begins to increase among people in their 50s. When a spinal canal narrows, nerves that run inside the canal, such as the cauda equina and nerve roots, are compressed causing symptoms like neuralgia, numbness, or paralysis (weakness) of the lower extremities, which is called Sciatica. In addition to numbness in both lower extremities, the syndrome includes discomfort in the groin, such as a sensation of warmth, or rectovesical symptoms like a feeling of residual urine after urination and constipation. These symptoms mostly appear when rising from a lying posture or walking movement. Such patients are unable to walk a long distance without frequent rests, the symptom which is called intermittent claudication. If pain or numbness in the lower extremities becomes worse during walking, or urination related discomfort is experienced together with symptoms in the lower extremities, those symptoms are likely caused by Lumbar Spinal Canal Stenosis. To determine the degree of stenosis, specific examinations such as MRI or MR Myelography are performed. For an accurate diagnosis, other examinations are also required to detect vascular lesions in the lower extremities, as intermittent claudication is a symptom of artery obstruction in the lower extremities as well (possibly caused by arterial sclerosis).

When the degree of stenosis is severe and the symptoms cannot be alleviated with medication therapy (oral administration of medicine) or nerve block injections, surgical treatment is available to reduce stenosis and relieve nerves. Please consult a Specialist in Spine and Spinal Cord Injury.

Fig.4Click to enlarge

Lumbar Degenerative Spondylolisthesis

Lumbar Degenerative Spondylolisthesis is a spinal condition in which one lumbar vertebra slips forward over the vertebra below, especially often occurs at the fourth lumbar vertebra in the middle-aged or older population. Although the cause is unknown, frequently with aging, intervertebral discs and surrounding joints and ligaments become loosened resulting in the instability of lumbar vertebrae, which allows a slippage that progresses with time. (Fig.5) The lower back pain caused by the Lumbar Degenerative Spondylolisthesis could be mild. However, progressed slippage causes Spinal Canal Stenosis, which results in intermittent claudication (pain and numbness in the lower extremities increase when walking for a long distance and ease when squatting down). When it progresses further, pain and numbness in the lower extremities are recognized even under resting condition. Generally, the symptoms appear in an upright position and ease in a seated position. In severe case, nerve block injections are often administered. However, when conservative treatments including medication therapy do not alleviate the symptoms, a surgical option should be considered for decompression of nerves or spinal fusion. Fig.6) It is recommended to consult a Specialist in Spine and Spinal Cord Injury at an early stage.

In our hospital, we use minimally invasive surgery techniques (MISt) whenever possible with the aid of our latest surgery system. The techniques are applied even for spinal fusion. Please consult our specialists.

Fig.5Click to enlarge
Fig.6Click to enlarge

Lumbar Degenerative Scoliosis (Kyphoscoliosis)

Degenerative Scoliosis (Kyphoscoliosis) is a condition when a body trunk cannot be held in a correct position due to age-related degeneration of intervertebral discs or vertebrae as well as weakened lower back muscles. This musculoskeletal disorder occurs when spinal column bends laterally or forwardly, sometimes with a rotation (rotation deformity). The main symptom is lower back pain, but when a vertebral deformation or spinal distortion (rotation deformity) becomes severe and compresses nerves, it causes numbness and pain in the lower extremities or intermittent claudication. Advanced scoliosis causes difficulty in maintaining a good posture and interferes with daily activities. Mild symptoms are treated with conservative method, such as wearing a corset. However, surgical treatment is chosen for symptoms like lower back pain, numbing pain in the lower extremities, and poor postural balance that severely interferes with daily activities. Surgical treatment such as decompression of nerves or a corrective spinal fusion requires special techniques and highly specialized knowledge. It is recommended to consult a Specialist in Spine and Spinal Cord Injury.

Osteoporotic Spinal Compression Fracture

Osteoporosis is a condition in which the healthy balance of absorption and generation of bone tissue is broken and as a consequence, the bones become brittle losing mass. Such bones not only become porous but also the bone quality changes making their structure fragile. Osteoporosis is more common among post-menopausal women, as bone balance is influenced by female hormone. Fracture of brittle vertebrae due to osteoporosis is called compression fracture.(Fig.7

At an advanced stage of osteoporosis, compression fracture occurs without any strong impact, such as trauma of falling. Spinal fracture causes severe pain in the back. As collapsed spines do not grow back to the original shape, the damaged bones fuse as they are, and the aching pain will be alleviated. Even after the pain is gone, a common damage remains, such as stooped posture, hunched back or height loss. As the first fracture is indicative of a risk for more down the road, not only the early treatment for the fracture but preventive measures for osteoporosis are also critical. Measurement of bone mass is relatively easy and can be done in our hospital. If we find a reduction of bone mass, we administer medications that increase bone mass and density. If a compression fracture has already occurred, the acute pain can be alleviated using a corset or plaster, which also prevents spine degeneration. When the fracture is not properly treated at a hospital, the broken bone may not fuse prolonging the pain. For this case, the affected space inside the collapsed vertebra is enlarged with an inflated balloon and bone cement (BKP) is injected in that space to fuse the bone.(Fig.8) Sometimes, the instability or degeneration of fractured bones blocks the related nerves and causes paralysis of the lower extremities. For this case, decompression of nerves or fusion treatment is vital. It is highly recommended to see a Specialist in Spine and Spinal Cord Injury without delay.

Fig.7Click to enlarge
Fig.8Click to enlarge

Cervical Disc Herniation

As explained for lumbar vertebrae, each intervertebral disc lying between cervical vertebrae is functioning as padding and allowing mobility to a spinal column. Due to aging and other conditions, annulus fibrosus enveloping intervertebral discs may rupture, and that the inside content herniates, which is called Intervertebral Disc Herniation. (Fig.9)

The symptoms vary, depending on the direction of protrusion. However, spinal cord itself or nerve roots that branch off the spinal cord (branches of nerves) are compressed and diffused pain or numbness is admitted from one side of the cervical region to a shoulder, scapula, and arm. Muscular weakness may also be acknowledged. When a severe protrusion occurs at the center of a disc, it compresses spinal cord itself and symptoms like impaired finger dexterity, gait disorder, or rectovesical disorders, such as urinary frequency, urinary retention and urinary incontinence, set in. If severe pain or numbness cannot be cured with conservative treatments or neurological disorders develop due to the compressed spinal cord or nerve roots, surgical treatment is required at an early stage. If you experience any of the aforementioned symptoms, please see a Specialist in Spine and Spinal Cord Injury.

Fig.9Click to enlarge

Cervical Spondylotic Radiculopathy and Myelopathy (Cervical Myelopathy)

Damage of cervical spine or intervertebral disc is likely to cause growth of bone or cartilage called bone spur. This condition of degenerated cervical spine due to aging is called cervical spondylosis. When a bone spur compresses branches of nerves (nerve roots), acute pain in scapular region or upper extremities may be experienced. Symptoms like pain or numbness in the upper and lower extremities, motor paralysis, and urinary disturbance suggest a spinal cord compression. It is critical to see a Specialist in Spine and Spinal Cord Injury. An X-ray exam is required to detect the site and size of the bone spur as well as MRI/CT exams are useful to see the degree of neurologic symptoms and degeneration of the spinal cord. (Fig.10)

Mild numbness, sensory disorders, or pain is treated with medication therapy, and is followed by a routine follow-up. However, if those symptoms are not controlled and motor paralysis or muscular weakness is also recognized, surgical treatment is appropriate. In general, surgery procedure is taken through anterior approach (anterior decompression and fusion) (Fig.11) or posterior approach (laminoplasty)(Fig.12), depending on the size or site of the causal lesion that compresses the spinal cord. Spinal fusion may also be required, if instability is present due to causes like cervical spondylolisthesis or malalignment of cervical vertebrae. In either case, these surgeries require highly specialized knowledge and skills. Please consult our specialists.

Fig.10Click to enlarge
Fig.11Click to enlarge
Fig.12Click to enlarge

Thoracic Myelopathy (Herniation, Spondylosis)

Nerves in the spinal cord are classified into cervical cord, thoracic cord and lumbar cord (the cauda equina), according to the location. Thoracic Myelopathy is a condition in which the nerves in the thoracic cord are compressed for some reason causing neurological disorders. This illness is a relatively rare clinical condition. As thoracis vertebrae (the backbone) that surround thoracic cord are stabilized by the rib cage allowing less mobility, their age-related degeneration is considered to occur less frequently compared to cervical or lumbar vertebrae. The causes of the disease are as follows: (1) Thoracic Disc Herniation caused by protrusion of the intervertebral disc; (2) Degenerative Thoracic Spondylosis caused by a spinal cord compression due to a bone spur generated from age-related degeneration of thoracic spine; or (3) Ossification of Posterior Longitudinal Ligament or Ligamentum Flavum, as ossified vertebral ligaments, such as posterior longitudinal ligament or ligamentum flavum, make compression on the spinal cord.

The illness is common in the middle-aged or older population, and the initial symptom is usually numbness or weakness of the lower extremities. The symptoms gradually spread to the body trunk and a band-like pain also goes through the body trunk. Gait disorder and rectovesical disorders, such as urinary frequency, urinary retention and incontinence, develop at more advanced stage. When initial symptoms are admitted only in the lower extremities, it is difficult to obtain an accurate diagnosis immediately. Such conditions are likely treated as a disorder of lumbar vertebra. In fact, it is not rare to require time to reach an accurate diagnosis. If the symptoms persist in the lower extremities without any known cause, it is highly recommended to see a Specialist in Spine and Spinal Cord Injury.

Ossification of Posterior Longitudinal Ligament, Ossification of Ligamentum Flavum

Ossification of Posterior Longitudinal Ligament or Ligamentum Flavum is a condition in which spinal cord symptoms occur due to cervical or thoracis cord compression by ossified and thickened posterior longitudinal ligament that lies anterior to the spinal cord inside the spinal canal or ligamentum flavum that lies posterior to the spinal cord inside the spinal canal. Ossification of Posterior Longitudinal Ligament is found more often in the cervical vertebrae, whereas Ossification of Ligamentum Flavum is found more often at the thoracic-lumbar junction. When the spinal cord compression progresses, aching pain occurs in the cervical region or shoulder, numbness of upper and lower extremities is recognized, and impaired finger dexterity and gait disorder are experienced. For unknown reason, the illnesses occur more often in Asian male population at late middle age, especially in combination with diabetes. Certain group of patients are reported to have a hereditary predisposition to these disorders. If you have symptoms like difficulty in moving fingers or walking movement, surgical treatment is available. It is highly recommended to see a Specialist in Spine and Spinal Cord Injury.

Two operative methods are optimal: Anterior fusion in which ossification is removed from the front and vertebrae are fused by bone implantation; or expansive laminoplasty in which vertebral arch is formed from the back to enlarge the spinal canal. In addition to spinal cord decompression, spinal fusion with instrumentation from the back is performed, depending on the structure of ossification. (Fig.13) They are classified as Special Chronic Diseases by The Ministry of Health, Labour and Welfare. If you need the medical treatment, you may be eligible for public subsidy. Please contact your local town office or medical institution for more details.

Fig.13Click to enlarge
Fig.13Click to enlarge

Spinal Deformity (Adolescent Spinal Deformity, Adult Spinal Deformity)

A severely curved spinal column as a result of gradual progress of the curvature causes a problem of postural appearance, instability for standing, and severe lower back pain. Largely it is classified either into adolescent scoliosis that develops in the adolescent period or into degenerative kyphoscoliosis that is more frequently seen in older population. A corrective surgery for the spinal curvature is the appropriate option for adolescent scoliosis patients whose spinal curve progresses over 30 degrees, and for degenerative kyphoscoliosis patients whose daily activities are severely interfered due to hunched back, lower back pain, or limping gait. For aged individuals, previously, the corrective surgery was not considered for being too invasive and risky. However, with the novel techniques of minimally invasive surgery as explained below, corrective surgeries become less invasive and risky for aged patients. In practice, surgical treatment has been increasingly selected in clinical settings. (Fig.14)
If you are unable to alleviate pain due to a stooping posture, do not give up hope and consult us.

Minimally Invasive Spine Surgery

Our minimally invasive spine surgery techniques allow minimal skin incision and as a consequence relatively narrower muscular incision, which facilitates post-operative recovery.
Mainly, we offer four types of techniques:

(1) Endoscopic surgery: Microendoscopic Discectomy (MED) for lumbar disc herniation, Microendoscopic Laminotomy (MEL) as lumbar fenestration, and Cervical Microendoscopic Laminotomy (c-MEL)
(2) Transforaminal Lumbar Interbody Fusion (MIS-TLIF) with Percutaneous Pedicle Screw (PPS)
(3) Transforaminal Lumbar Interbody Fusion (XLIF) for lateral approach
(4) Balloon Kyphoplasty (BKP) for osteoporotic spinal compression fractures

Even in a major surgical treatment that requires a fusion from thoracic to pelvis in case of spinal deformity, partial use of minimally invasive spine surgery techniques, such as XLIF and PPS, significantly reduces bleeding during surgery, easing physical burdens for patients.

Surgery Statistics

  Posterior Lumbar Decompression Open PS (of which Thoracic-Pelvis Fusion) MIS-TLIF MED/MEL (of which Cervical Endoscopic Surgery) Cervical Foraminotomy (Posterior Cervical Fusion) Anterior Cervical Fusion XLIF OLIF XCORE Adolescent Scoliosis Surgery BKP Spinal Cord Tumor Anterior Thoracic and Lumbar Fusion Spinal Osteotomy Other surgeries Total

(May 2014 to March 2015)
Total in 2014 29 27
(2)
69 48 18
(3)
24 18 0 0 0 5 2 1 1 20 262

(April 2015 to March 2016)
Total in 2015 17 19
(2)
75 85
(7)
35 18 71 0 0 6 8 1 1 1 6 343

(April 2016 to March 2017)
Total in 2016 29 16 59 136
(5)
15
(3)
14 21 32 4 11 56 0 0 0 26 419

(April 2017 to March 2018)
Total in 2017 37 7 80 128
(2)
26
(1)
21 11 50 11 1 48 3 1 1 34 533
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MAP

3-57-1 Yoyogi Shibuya-ku Tokyo
TEL:+81-3-5308-0511

About 5-minute walk from Sangubashi Station (Odakyu Line)
About 8-minute walk from Yoyogi Station (JR Yamanote Line)
10 minutes by taxi from Shinjuku Station South Exit

Sangubashi Spine Surgery Hospital

3-57-1 Yoyogi Shibuya-ku Tokyo TEL:+81-3-5308-0511

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