Articles January 27, 2016
The vast majority of patients with axial spine and extremity radicular symptoms will improve with a non-surgical and natural approach that allows the body to heal. The limited group of patients that do not improve may require surgical treatment to complete their healing process. Surgical results can be excellent with the appropriate indications and with improved minimally invasive back surgery (MIS) techniques. It is exciting, as a veteran surgeon, to utilize the next generation MIS techniques with real patient value and benefit. Not all minimally invasive approaches are created equal. A single posterior approach with minimized injury to the multifidus makes the most sense.
The goal of cervical and lumbar spine surgery is to allow decompression of a compressed nerve, and if needed, address a painful unstable motion segment by either an artificial disc or fusion. These surgeries are traditionally completed from combinations of anterior, posterior, and lateral approaches. The posterior approach is the only one that allows decompression and fusion from one incision, and the ability to treat any spinal level. Lateral approaches cannot address the L5-S1 disc level, due to the position of the iliac wing, and may at times require a second incision from a posterior approach for additional decompression/instrumentation. The anterior approaches may require a second posterior incision to complete the decompression of the nerves. (Cervical and Lumbar artificial discs currently can only be done through an anterior approach.)
The most recent thinking is that lumbar degeneration above the level of a previous fusion is much less from the loss of motion at the fusion and more from the posterior muscle injury associated with loss of dynamic stabilization. This is associated with standard posterior approach surgical techniques. Supporting this is considering that childhood congenital spine fusions do not have this adjacent level degeneration, and their paraspinous muscles are normal. In my practice, sparing the multifidus and longissimus is essential to later recovery and better long term results. The multifidus has a single origin on a spinous process and spreads obliquely and caudally to insert over 3 levels, and is responsible for the dynamic stability of the spine.
Many current posterior MIS procedures still use a midline approach, thus taking down the origin of this dynamic stabilizer of the lumbar spine. I have had the best results with a minimally invasive back surgery posterior approach that keeps the multifidus attached to the spinous process, and separates the muscle fibers. This MIS technique results in less paraspinous muscle tissue damage and a stronger spine during rehabilitation after surgery.
Chiropractic care excels at facilitating the natural process of healing and getting the patient back to life without surgical treatment. For those patients who really do need surgery, saving the multifidus makes all the difference in speed of recovery and overall outcome.
Download the original publication: Save-The-Multifidus