Dr. Epstein has written extensively on
disc herniations involving the spine. Disc herniations are defined as an
extrusion (popping out) of the cushion between the vertebral bodies. When discs
herniate in the neck, they may compress the cervical spinal cord (central),
and/ or nerve roots (off to the side). Nerve root compression can produce
numbness, tingling or weakness, while spinal cord compression may result in the
loss of sensation, weakness in the legs, or even severe paralysis. Only a
subset of patients with disc herniations may require surgery. When these
operations are required they can be performed from the front or back of the
neck (cervical), mid back (thoracic), or lower back (lumbar spine).
Epstein
NE, Epstein JA: Lumbar intervertebral disc herniation teenage children:
Recognition and management of associated anomalies. Spine, 9(4): 427-423,1984
Epstein
NE, Epstein JA, Carras R, Hyman RA, Vishnubakhat SM: Far lateral disc
hernia ion: diagnosis and surgical management. Neuron - Orthopedics (Springer - Vela), 1(1): 37-44, 1986.
Epstein
NE, Syrquin M, Epstein JA, Decker RE: Intradural disc herniations in
the cervical, thoracic, and lumbar spine: Report of three cases and review of
the literature. J Spinal Disord,
3(4): 396-403, 1990
Epstein
NE, Epstein JA, Carras, Hyman R: Far lateral disc herniations and
associated structural abnormalities: Evaluation of 60 patients and the
comparative value of CT, MRI, and Myelo -CT in the diagnosis and management. Spine, 15(6): 534-539, 1990
Epstein
NE, Epstein JA: Limbus vertebral fractures of the lumbar spine and
spinal stenosis in five adolescents with further evaluation of Type III
fractures. Neuro - Orthopedics (Springer-Verlag),
9: 33-52, 1990
Epstein
NE, Syrquin M, Epstein JA, Decker RE: Intradural disc herniations in
the cervical, thoracic, and lumbar spine: Report of three cases and review of
the literature. J Spinal Disord,
3(4): 396-403, 1990
Epstein NE, Epstein JA: Limbus lumbar vertebral fractures in 27 adolescents and
adults. Spine 16(8): 962-966, 1991
Epstein
NE: Lumbar surgery for 56 limbus fractures emphasizing non -calcified
Type III lesions. Spine, 17 (12):
1489-1496, 1992
Epstein NE, Epstein JA: Far lateral
lumbar disc herniations. In Neurosurgical Operative Atlas, SS
Rengachary, R Wilkins (eds), AANS Publications Committee, Vol. 5: 185-197, 1996
Epstein NE: Far lateral and foraminal disc herniations.
In Textbook Of Neurological Surgery, Batjer H, Loftus C (eds),
Lippincott-Raven (pub), Philadelphia, PA, (in press)
Epstein NE: A review of laminoforaminotomy for the management of
lateral and foraminal cervical disc herniations or spurs, Surgical Neurology 57(4): 226, 2002
Epstein
NE: Anterior dynamic plates in complex
cervical reconstructive surgeries. Journal of Spinal Disorders, 15(3): 221-227, 2002
Epstein
NE: Anterior cervical
dynamic ABC plating with single level corpectomy and fusion in 42 patients. Spinal Cord, 41: 153-158, 2003
Spinal stenosis
is the fancy term for narrowing of the spinal canal. You can be born with a
narrowed spinal canal (congenital stenosis), or may develop arthritic changes
as you age (acquired stenosis) which narrow your spinal canal. In the older population,
spinal stenosis is much more common than disc disease. Arthritic changes may
include calcified discs, calcified ligaments, calcified facet joints. Narrowing
(stenosis) in the neck (cervical), mid back (thoracic), or lower back (lumbar
spinal canal) may compress nerve tissue and produce numbness, tingling,
weakness, or paralysis. The treatment includes operations from the front or
back of the spine at any of these levels.
Click the links below to view related articles:
Epstein
NE, Epstein JA, Carras R, Vishnubhkat, SM, Hyman R: Co-existing
cervical and lumbar spinal stenosis: Diagnosis and management. Neurosurgery, 15(4): 489-496, 1984.
Epstein NE, Epstein JA: Individual and coexistent lumbar and
cervical spinal stenosis: diagnosis and surgical management. In Spine; State
of the Art Reviews, Emery Hopp (ed), Hanley and Belfus (pub), Vol. 1(3):
401-420, 1987
Epstein
NE, Epstein JA: Cervical spine stenosis. In Principles of Orthopedic
Practice, Roger Dee, (ed), McGraw Hil l (pub), New York, Vol. 2 Chapter
57-Section B: 982-987, 1988
Epstein
NE, Epstein JA, Carras R: Cervical spondylosis, stenosis, and
myeloradiculopathy in patients over 65:
Diagnostic techniques and management. Neuro-Orthopedics (Springer-Verlag), 6(1): 13-32,1988
Epstein
NE, Epstein JA, Carras R: Coexisting cervical spondylotic myelopathy
and bilateral carpal tunnel syndromes. J
Spinal Disorders, 2(1) 36 - 42, 1989
Epstein
NE, Blanck R, Epstein JA: Problems in the diagnosis of coexisting
cervical spondylotic myelopathy in the presence of multiple sclerosis: Report
of 5 cases. Neuro-Orthopedics (Springer-Verlag),
10: 15-26, 1990
Epstein
NE, Epstein JA: Operative management of cervical spondylotic
myelopathy: technique and results of laminectomy. In The Cervical Spine
-Third Edition, Clark CR (ed), Lippincott-Raven (pub), Philadelphia,
Chapter 62: 829-838, 1998
Epstein
NE, Epstein JA, Carras R, Lavine LS: Degenerative spondylolisthesis
with an intact neural arch: A review of 60 cases with an analysis of clinical
findings and the development of surgical management. Neurosurgery, 13(5): 555-561,1983
Epstein JA, Epstein NE: Chapter: Lumbar
spondylosis and spinal stenosis. In Neurosurgery, Robert H Wilkins, and
Setti S. Rengachery (eds), McGraw Hill
(pub), New York, Pt IX, 94, 1985.
Epstein NE, Epstein JA: Surgery of the lumbar spine: lumbar
spinal stenosis. In The Lumbar Spine, Camins MB, O’Leary PF (eds), Raven
Press, New York, 149-161, 1987
Epstein
NE, Schwall G: Thoracic spinal stenosis: diagnostic and treatment
challenges. J Spinal Disord, 7(3): 259-269, 1994
Epstein
NE, Epstein JA: Lumbar spinal stenosis. Neurological Surgery, 4th
Edition, Youman JR (ed), Dunsker S (Section Editor), W.B. Saunders (pub),
Philadelphia, Vol. 3, Chapter 106: 2390-2415, 1996
Epstein NE, Epstein JA: Lumbar decompression
for spinal stenosis; surgical indications and techniques with and without
fusion. In The Adult Spine, Principles And Practice - Second Edition,
Frymoyer, John W (ed), Lippincott -
Raven (pub), Philadelphia, Chapter 97, Vol. II: 2055-2088, 1997
Epstein
NE: Surgical management of lumbar stenosis: decompression and
indications for fusion. Neurosurg Focus 3(2): Article 1: 1-14, August 1997
Epstein NE: Clinical Controversy: lumbar spinal stenosis. Surgical Neurology, 50:3-10, 1998
Epstein NE: Diagnosis of Epidural Lipomatosis in the Lumbar
Spine: Report of 3 Cases. The Spine Journal (in press 2004)
Epstein NE: Section on degenerative lumbar spinal stenosis. In Youman’s
Neurological Surgery, 5th Edition, Richard Winn (ed), W.B. Saunders,
Philadelphia PA, (in press)
Click the links below to view related articles:
Click the links below to view related articles:
When there is too
much motion between the bones of the spine (vertebral bodies) the excess motion
can lead to pain, compression of the nerve tissue, and nerve damage. In the
neck (cervical spine) and lower back (lumbar spine) instability or a “slip” can
be seen on X-rays taken with the patient bending forward and backward. More
long-standing slippage can be seen on regular X-rays, and MR or CT scans. Slips
can be due to arthritic changes in the bones and ligaments, previous injury, or
can follow operations. Operations performed to “stabilize” the slip are called
fusions. Fusions can be performed from the front or back of the neck (cervical
spine: anterior diskectomy, corpectomy, or circumferential surgery), mid back
(thoracic spine), or lower back (microscope assisted diskectomy/laminotomy,
laminectomy [non-instrumented, instrumented fusions].
Epstein
NE: Primary fusion for the management of “unstable” degenerative
spondylolisthesis. Neuro - Orthopedics (Spinger-Verlag),
23:45-52,1998
Epstein
NE: Laminectomy with posterior wiring and fusion for cervical OPLL,
spondylosis, OYL, stenosis, and instability:
A study of 5 patients. J Spinal Disord 12: 461-466, 1999
Epstein NE: Technical
Note: Unilateral posterior resection of cervical disc and spondylostenosis with
contralateral fusion for instability, Surgical
Neurology 56:
256-258, 2001
Epstein
NE: Cervical laminectomy
with or without posterior wiring and fusion or laminoplasty for the management
of spondylostenosis and ossification of the posterior longitudinal ligament, Surgical Neurology, 58: 194-208, 2002
Epstein
NE: Cervical laminectomy
with or without posterior wiring and fusion or laminoplasty for the management
of spondylostenosis and ossification of the posterior longitudinal ligament, Surgical Neurology, 58: 194-208, 2002
Epstein
NE: Anterior cervical
dynamic ABC plating with single level corpectomy and fusion in 42 patients. Spinal Cord, 41: 153-158, 2003
Epstein
NE: An analysis of combined
Inductive-Conductive Matrix and autologous bone graft in 61 posterior cervical
fusions. Spinal Surgery 17(1): 1-6,
2003
Epstein NE: Circumferential cervical surgery for
Ossification of the Posterior Longitudinal Ligament: A Multianalytic outcome
study. Spine, 29 (12):1340-1345, 2004
Epstein NE: Lumbar Synovial Cysts: a
review of diagnosis, surgical management, and outcome assessment. J Spinal
Disord Tech. 2004 Aug;17(4):321-5.
Epstein NE. Posterior Cervical Fusion Utilizing A Modified
“Screwless” Vertex System A Preliminary
Report in 8 Patients. Spinal Surgery; 18(2): 63-70, 2004
Epstein NE. Dynamic Anterior Cervical Plates for Multilevel Anterior Corpectomy and Fusion With
Simultaneous Posterior Wiring and Fusion: Efficacy and Outcomes.Spinal Cord (in
press 2005)
Epstein NE: Complications and Outcome in Dynamic Plated Single Level
Anterior Corpectomy and Fusion Including Two Level Complete Diskectomies. The
Spine Journal (Submitted 2005)
The
posterior longitudinal ligament is located in front of the nerve tissue in the
neck (cervical), mid back (thoracic), and lower back (lumbar spine). In some
patients, this ligament can become calcified (ossified). Ossification of this
posterior longitudinal ligament [OPLL] can compress the spinal cord or nerve
roots in the spinal canal. It is most frequently found in the neck (cervical).
OPLL can produce numbness, tingling, weakness, and even paralysis. Operations
performed to remove OPLL can be extensive. If performed in front of the neck,
it may require the removal of several vertebral bodies, the placement of a
graft and plate, followed by fusion of the back of the neck (circumferential
surgery). In some other patients, surgery from the back of the neck
(laminectomy with/without fusion) can be performed. Many patients demonstrate
significant postoperative improvement.
Epstein
NE, Epstein JA: Simultaneous ossification of the posterior longitudinal
ligament in the cervical and lumbar spinal canal. Neuro-Orthopedics (Springer-Verlag), 8: 45-53, 1989
Epstein
NE: Diagnosis and surgical management of ossification of the posterior
longitudinal ligament. Contemporary
Neurosurgery, 22: 1-6, 1992
Epstein
NE: Ossification of the Posterior Longitudinal Ligament: diagnosis and
surgical management. Neurosurgical
Quarterly, 2(3): 223-241, 1992
Epstein
NE: Advanced cervical spondylosis with ossification into the posterior
longitudinal ligament and resultant neurologic sequelae. J Spinal Disord, 9(6):
477-484, 1996
Epstein
NE: Ossification of the posterior longitudinal ligament. In OPLL:
Ossification of the Posterior Longitudinal Ligament, Yonenobu K, Sakou
T, Ono K (eds), Springer-Verlag, Tokyo, Japan, 85-93, 1997
Epstein
NE, Epstein JA: The surgical management of ossification of the
posterior longitudinal ligament (OPLL).
Harefuah ( Israeli Medical BI-Weekly Journal honoring Aharon Beller
M.D.), Moshe Feinsod M.D. (ed), 67-74, 1997
Epstein
NE: Ossification of the yellow (OYL) ligament and spondylosis and or
ossification of the posterior longitudinal (OPLL) ligament of the thoracic and
lumbar spine. J Spinal Disord 12(3): 250-256, 1999
Epstein
NE: Simultaneous cervical diffuse idiopathic skeletal hyperostosis and
ossification of the posterior longitudinal ligament resulting in dysphagia or
myelopathy in two geriatric North Americans. Surgical Neurology 53(5): 427-31, 2000
Epstein
NE: Identification of
ossification of the posterior longitudinal ligament extending through the dura
on preoperative CT examination of the cervical spine. Spine, 26(2): 182-186,
2001
Epstein, NE: In-Vitro
Characteristics of Cultured Posterior Longitudinal Ligament Tissue, Spine 27(1): 56-58, 2002
Epstein
NE: Review article:
diagnosis and surgical management of cervical ossification of the posterior
longitudinal ligament, The Spine Journal
2: 436-449, 2002
Epstein
NE: Ossification of the
cervical posterior longitudinal ligament: A review. Neurosurgical Focus 13(2): 1-10, 2002
Epstein NE: Familial Ossification of the Posterior Longitudinal
Ligament Found in 4 North American Families. Spinal Surgery; 18(2): 57-62, 2004
Click the links below to view related articles:
Tumors affecting the spine can
include benign (non-cancerous) tumors. They can be located in the bones, in the
spinal cord itself, or outside of the cord.
Tumors
originating within the spinal cord itself include benign astrocytomas, benign
ependymomas, and occasionally malignant gliomas or mestastases.
Epstein
F, Epstein
NE: Surgical management of “holocord” intramedullary spinal cord
astrocytomas in children. J Neurosurg, 54(6):
829-832, 1981
Epstein NE, Epstein F, Allen J: Intractable facial pain associated with
ganglioglioma of the cervicomedullary junction: A case report. Neurosurgery 10(5): 612-616, 1982
Epstein
NE, Buchar S, Gavin R, Hyman RA, Zito J: Failure to diagnose conus
ependymomas by magnetic resonance imaging. Spine,
14(1): 134-137, 1989
Epstein
NE, Frank I: Chronic dysphagia, vomiting, and gastroesophageal reflex
as manifestations of a brain stem glioma. Pediatric
Neuroscience, 15(5): 265-268, 1989
These are usually (95%) benign tumors originating
from the covering of the nerve tissue (dura). They are found mostly in the neck
(cervical) or mid back (thoracic) spinal canal. MR studies performed with dye
(Gadolinium DTPA) best demonstrate these tumors. CT examinations can evaluate
the degree of calcification while telling you about the surrounding bones. Many
of these tumors can be completely removed, often from the back of the spine.
Epstein NE. Clear Cell
Meningioma of the Cauda Equina in an Adult. A Case Report and Literature
Review. J Spinal Disord and Tech (2004)
These are tumors that originate from specialized
cells, which surround nerves (Schwann cells). They too are typically benign,
but are found throughout the neck (cervical), mid back (thoracic), and lower
back (lumbar spinal canal). Complete excision is feasible in the majority of
cases, while a small subset may not be fully removable. Again, a small subset
of these tumors may prove malignant, requiring additional radiation and/or
chemotherapy.
Epstein NE: Clinical Opinion: Resection of massive
retroperitoneal tumor extending into L5 vertebral body: Controversies in
surgical management. J Spinal Disord,
10(2): 176-181, 1997
Benign
tumors originating in the bone include osteomas which may become malignant.
Others include aneurismal bone cysts.
Epstein
NE, Benjamin V, Pinto R, Budzilovich G: Benign osteoblastoma of a
thoracic vertebra: Case Report. J
Neurosurg, 53(5): 710-713, 1980
Click the links below to view related articles:
Operations can be done from the
front of the neck (cervical spine) to remove disc herniations. First, a
horizontal incision is made in the neck
(side to side in a wrinkle). Once the front of the spine is exposed, an
X-ray is taken on the operating table to confirm the operative level.
Microinstruments are used under an operating microscope to remove the disc and
arthritic tissue (spur, spondylosis arthrosis). A fusion is next performed with
a bone graft. The patient’s bone (autograft) is taken from the hip (iliac
crest: not the hip joint but the curved bone of the pelvis). The patient’s bone
heals better and faster in most studies than cadaver (allograft) bone. A
titanium plate is placed over the bone graft to keep it in place. An X-ray
taken on the operating table confirms placement of the bone graft and plate. A
drain is placed in the neck and the wound is closed. At the end of the
operation, patients awaken in a neck brace (CTO: cervical thoracic orthosis),
are examined (to make sure they are OK), and are brought to the recovery room.
A CT scan of the neck (cervical spine) performed the night after surgery check
graft/plate placement. Patients are transferred for observation to the
intensive care unit (older patients) or the step down unit. Most patients are
discharged within 2-3 days, depending on their needs.
Epstein
NE, Syrquin M, Epstein JA, Decker RE: Intradural disc herniations in
the cervical, thoracic, and lumbar spine: Report of three cases and review of
the literature. J Spinal Disord,
3(4): 396-403, 1990
Epstein
NE: Anterior cervical diskectomy and fusion without plate
instrumentation in 178 patients. J Spinal Disord 13: 1-8, 2000
Click the links below to view related articles:
Excision of two adjacent discs
may also require removal of the intervening vertebral body if arthritic changes
extend behind that body (bone). This operation is similar to that described for
the 1 level diskectomy/fusion but requires more extensive decompression
(removal of 2 discs and arthritis) with a longer graft obtained from the
patient’s hip (iliac crest). Arthritis is removed with diamond drills and microinstruments
under the operating microscope with monitoring the nerve potentials of the
spinal cord (SSEPs) and nerves (EMGs).
Epstein
NE: Reoperation Rates For Acute Graft Extrusion and Pseudarthrosis
Following One Level Anterior Corpectomy and Fusion With and Without Plate
Instrumentation: Etiology and Corrective Management. Surgical Neurology 56: 73-81, 2001
Epstein
NE: Anterior dynamic plates in complex
cervical reconstructive surgeries. Journal of Spinal Disorders, 15(3): 221-227, 2002
Epstein
NE: Delayed iliac crest
autograft fractures following plated single level anterior corpectomy with
fusion. J Spinal Disord 15(5):
420-424, 2002
Epstein
NE: Can recurrent pain be a
signal of delayed autograft strut fracture following anterior cervical surgery?
A radiographic correlation. Spinal
Surgery (Japan) 16(3):
197-205, 2002
Epstein
NE: Anterior cervical
dynamic ABC plating with single level corpectomy and fusion in 42 patients. Spinal Cord, 41: 153-158, 2003
Epstein NE: Does donor site reconstruction affect postoperative
pain following single level anterior corpectomy with fusion? J Spinal Disord Tech 16(1):20-26, 2003
Click the links below to view related articles:
Patients with arthritis, and particularly, multiple level
OPLL, may require the removal of several vertebral bodies (bones) of the neck
(cervical spine). The approach from the front of the neck requires a longer
horizontal incision. Intraoperative X-rays are similarly obtained to confirm
the level of surgery after retractors (instruments to keep the tissues apart)
are placed. Diamond drills, microinstruments, an operating microscope, and
spinal cord monitoring are critical to successfully remove OPLL. Here, usually,
a long, straight cadaver (allograft) graft is required to span multiple levels;
a hip graft here is usually too curved and short. A longer titanium plate is
placed over the graft. To reinforce and help prevent these larger grafts/plates
from coming out, under the same anesthesia, a fusion from the back of the neck
is performed.
Click the links below to view related articles:
Fusions performed from the back of the neck to stabilize
multilevel anterior (front) cervical (neck) operations, utilize a
rod/eyelet/braided titanium cable system wired to the bones in the back of the
neck (spinous processes). These fusions require the use of bone graft taken
from the patients’ hip (autograft not from the hip joint but the iliac crest).
Epstein NE: The surgical management
of ossification of the posterior longitudinal ligament in 51 patients. In The
Yearbook of Neurology and Neurosurgery, RH Wilkins (ed), Mosby (pub), New
York, 470, 1995
Epstein
NE: Cervical ossification of the posterior longitudinal ligament. In Neurosurgery-Second
Edition, Wilkins RH, Rengachary
Ss(eds), McGraw - Hill (pub), New York,
Vol. III, Chapter 383: 3781-3787, 1996
Epstein
NE: Circumferential surgery for the management of ossification of the
posterior longitudinal ligament. J Spinal
Disord, 11(3): 200-207, 1998
Epstein NE: The value of anterior cervical plating in
preventing vertebral fracture and graft extrusion following multilevel anterior
cervical corpectomy with posterior wiring/fusion: Indications, results, and
complications. J Spinal Disord 13: 9-15, 2000
Epstein NE:
Anterior Approaches To Cervical Spondylosis and OPLL: Review of
Operative Technique and Assessment of 65 Multilevel
Circumferential Procedures. Surgical
Neurol, 55(6): 313-324, 2001
Epstein NE, Hollingsworth R,
Nardi D, Singer J: Can airway complications following multilevel
anterior cervical surgery be avoided? J Neurosurg ( Spine 2) 94: 185-188, 2001
Epstein NE: A comparative
analysis of plate/graft failure with correction following
circumferential cervical spinal surgery, Spinal Surgery 16(1): 1-8, 2002
Epstein
NE: Chapter 43:
Ossification of the Posterior Longitudinal Ligament of the Cervical Spne:
Clinical, Neurodiagnostic, and Circumferential Surgical Management, p. 575-603 In
Omurilik ve Omurga Cerrahisi, 1st Edition, M Zileli, A.F. Ozer
(Eds), Tpian A.S., Medikon A.S., 2002
Epstein
NE: An analysis of combined
Inductive-Conductive Matrix and autologous bone graft in 61 posterior cervical
fusions. Spinal Surgery 17(1): 1-6,
2003
Epstein NE: Circumferential cervical surgery for
Ossification of the Posterior Longitudinal Ligament: A Multianalytic outcome
study. Spine, 29 (12):1340-1345, 2004
Epstein NE: Dynamic Anterior Cervical Plates for Multilevel Anterior Corpectomy and Fusion With Simultaneous Posterior Wiring
and Fusion: Efficacy and Outcomes. Spinal Cord (in press 2005)
Epstein NE, Herkowitz HN, Yonenobu Y. Chapter 52: Ossification of the
Posterior Longitudinal Ligament. In Spine Surgery: Techniques, Complication
Avoidance, and Management 2nd Edition. Benzel EC (ed), Chruchill
Livingstone (pub), (in press)
Epstein
NE: Bennett G: Chapter 58:
Ossification of the posterior longitudinal ligament (pg. 729-43. In Spine
Surgery: Techniques, Complication Avoidance, and Management, E Benzel (ed),
Churchill Livingstone (pub), New York 2005
Epstein
NE: Circumferential Surgery
for ossification of the posterior longitudinal ligament of the cervical spine.
In Spine Surgery- Case Studies, Vaccaro AR (ed), Thieme (pub), New York,
(in press)
Epstein
NE: Ossification of the
posterior longitudinal ligament. In Textbook Of Neurological Surgery,
Batjer H, Loftus C (eds), Lippincott-Raven (pub), Philadelphia PA, (in press)
Click the links below to view related articles:
Removal of a disc located off to one side of the spinal
canal is performed in some instances from the back of the neck. This usually
requires removing a portion of the bone in the back of the neck (laminotomy)
above and below that disc herniation. Disc herniations can be removed utilizing
diamond drills for bone removal, and microinstruments under the operating
microscope. Spinal cord and nerve root monitoring (SSEP, EMG) employed
throughout add to the safety of surgery.
Epstein JA, Epstein NE: Complications of
cervical laminectomy. How to avoid them, diagnosis and treatment. In Cervical
Spine II, H. Sherk (ed), Springer-Verlag (pub), New York, Chapter 3.1:
171-178, 1989
Epstein NE: A review of
laminoforaminotomy for the management of lateral and foraminal cervical disc herniations or spurs, Surgical Neurology 57(4): 226, 2002
Epstein
NE: Posterior approaches in the management of
cervical spondylosis and ossification of the posterior longitudinal ligament.”
Surgical Neurology, 58: 194-208,
2002
Epstein NE: Laminectomy for cervical myelopathy. Spinal Cord 41; 317-327, 2003
Epstein NE: Posterior Decompression For Radiculopathy:
Laminoforaminotomy. Cervical Spine Surgery Atlas, 2nd Edition,
Herkowitz H (ed), Lippincott Williams & Wilkins, Chapter 12:157-166, 2004
Patients with compression of the spinal cord over several
levels may require a laminectomy. A laminectomy includes removal of bone (the
laminae) from the back of the neck. Select older patients with significant
arthritic disease or calcified discs in the front of the spine may benefit from
this operation if they have a good cervical curvature, and their spine is not
straightened or bent forward. Those with arthritic disease behind the spinal
cord and a normal spinal curvature can have surgery, performed through the back
of the spine.
Epstein NE: Myelopathy:
Laminectomy, Cervical Spine Research Society Textbook, 4th Edition,
Clark CC (ed), Lippincott Williams and Wilkins, (in press)
Epstein
NE: Cervical Myelopathy:
Posterior Approach-Laminectomy. In The Spine, 3rd Edition.
Rothman and Simeone (ed), Elsevier (pub), Philadelphia, (in press)
Epstein NE: Posterior Decompression For Radiculopathy:
Laminoforaminotomy. Cervical Spine Surgery Atlas, 2nd
Edition, Herkowitz H (ed), Lippincott Williams & Wilkins, Chapter
12:157-166, 2004
Epstein NE: Myelopathy: Laminectomy, Cervical Spine Research Society
Textbook, 4th Edition, Clark CC (ed), Lippincott Williams and
Wilkins, (in press)
Epstein
NE: Cervical Myelopathy:
Posterior Approach-Laminectomy. In The Spine, 3rd Edition.
Rothman and Simeone (ed), Elsevier (pub), Philadelphia, (in press)
When patients undergo multilevel laminectomy, fusion may be
required. Fusions from the back of the neck can utilize wires alone or
rods/eyelets with wires.
Epstein
NE: Laminectomy with posterior wiring and fusion for cervical OPLL,
spondylosis, OYL, stenosis, and instability:
A study of 5 patients. J Spinal Disord 12: 461-466, 1999
Epstein NE: Technical Note: Unilateral posterior resection of cervical
disc and spondylostenosis with contralateral fusion for instability, Surgical Neurology 56:
256-258, 2001
Epstein
NE: Cervical laminectomy
with or without posterior wiring and fusion or laminoplasty for the management
of spondylostenosis and ossification of the posterior
longitudinal ligament, Surgical
Neurology, 58: 194-208, 2002
Epstein NE. Posterior Cervical Fusion Utilizing A Modified
“Screwless” Vertex System A Preliminary
Report in 8 Patients. Spinal Surgery; 18(2): 63-70, 2004
Laminectomy may be required for removal of tumor, decompression of
stenosis, or removal of discs from the mid back (thoracic) spine.
Epstein
NE, Schwall G: Thoracic spinal stenosis: diagnostic and treatment
challenges. J Spinal Disord, 7(3): 259-269, 1994
Epstein NE: Clinical Opinion: Thoracic ossification of the
posterior longitudinal ligament, ossification of the yellow ligament from
T9-T12, with superimposed acute T10-T11 disc herniation: Controversies in
surgical management. J Spinal Disord,
9(5): 466-450, 1996
Epstein NE: Transthoracic and
transabdominal approach to T9-T12 ossification of the posterior longitudinal
ligament with herniated disc/stenosis. In Spine Surgery- Case Studies,
Vaccaro AR (ed), Thieme (pub), New York, (in press)
Click the links below to view related articles:
If a disc herniation compresses one specific nerve root and
is not accompanied by significant arthritic changes or instability (too much
slippage), a microscope-assisted diskectomy may be appropriate. To adequately
expose the nerve root and accompanying arthritic changes or stenosis, more bone
can be removed (laminotomy, partial laminectomy). Once the pressure is taken
off the nerve root (decompressed), the disc space is entered to remove
additional loose free fragments and reduce the risk of disc recurrence (another
piece of disc popping out). Although “fashionable” (minimally invasive)
alternatives are now available, many carry a higher risk of infection and
spinal fluid leak. Furthermore, the full extent of disease may not be
recognized, limiting the patient’s recovery.
Epstein
NE, Epstein JA: The surgical management of lumbar foraminal and far
lateral herniated discs complicated by vertebral limbus fractures. Neuro-Orthopedics (Springer-Verlag), 17/18: 173-178, 1995
Epstein NE: Evaluation of varied surgical approaches used in the management of
170 far lateral lumbar disc herniations: Indications and results. J Neurosurg, 83: 648-656, 1995
Epstein NE: Lumbar Laminectomy for the Resection of Synovial Cysts and Coexisting Lumbar
Spinal Stenosis or Degenerative Spondylolisthesis: An Outcome Study. Spine
Spine. 2004 Apr 23;29(9):1049-55.
Epstein
NE: Nerve root complications of percutaneous laser assisted diskectomy
performed at outside institutions: A technical report. J Spinal Disord, 7(6): 510-512, 1994
Epstein
NE: Laser assisted diskectomy performed by an internist resulting in
cauda equina syndrome: Technical note. J
Spinal Disord, 12(1): 77-79,
1999
For patients with more extensive arthritic disease of the
spine, an operation removing several lower back bones (laminae) may be
warranted. These procedures remove
arthritic disease (spur, spondylosis, ossified yellow ligament), provide more
room for narrowed spinal canals (decompress stenosis), and may or may not
require excision of disc herniations, Together, X-rays, MR, and CT studies
define the full extent of arthritic disease. Many of these operations are
performed in older patients (50’s-80’s), although a subset born with narrowed
spinal canals may develop symptoms earlier (30’s, 40’s). If there is no
evidence for abnormal motion between bony levels (no slip, instability),
multilevel laminectomy without fusion may be the appropriate operation.
Furthermore, if the amount/extent of bone removed during the decompression
affects stability, a fusion may be required.
Epstein
JA, Epstein
NE: Lumbar spinal stenosis. In Surgery of the Spine -A combined Orthopedic
and Neurosurgical Approach, GFG
Findlay and R. Owens (eds), Blackwell Scientific (pub), Oxford England, Chapter 41: 719-732, 1992
Epstein
NE, Hood DC: A comparison of surgeon’s assessment to patient’s self
analysis (Short Form 36) after far lateral lumbar disc surgery: An outcome
study. Spine, 22(20): 2422-2428, 1997
Epstein
NE: Surgical management of lumbar stenosis: decompression and
indications for fusion. Neurosurg Focus 3(2): Article 1: 1-14, August 1997
Epstein
NE: Decompression in the surgical management of degenerative
spondylolisthesis: Advantages of a conservative approach in 290 patients. J Spinal Disord, 11(2): 116-122, 1998
Epstein NE: Foraminal and far lateral disc herinations: Surgical
alternatives and outcome measures. Spinal
Cord 40: 491-500, 2002
Epstein
NE: Chapter 55: Surgery for Far Lateral Lumbar Disc
Herniations.p.719-738, In Omurilik ve Omurga Cerrahisi, 1st Edition, M Zileli, A.F.
Ozer (Eds), Tpian A.S.,
Medikon A.S., 2002
Epstein NE: Chapter 168: Far Lateral Lumbar Disc Herniations: Diagnosis
and Surgical Management. In Operative Neurosurgical Techniques, 5th
Ed., Schmidek, Sweet.
Elsevier, 2004
Epstein NE: Review Article/Lumbar Synovial Cysts, A Review of Diagnosis,
Surgical Management, and Outcome Assessment. J Spinal Disorder Tech, Vol
17(4):321-325,
August, 2004
If patients have evidence that the spine is moving too much
(unstable) on X-rays (plain X-rays, flexion/extension views), MR or CT studies,
a fusion may be required at the time of surgery. Furthermore, where the
operation includes the removal of bone needed for stability, fusions may be
warranted. These operations are typically performed in conjunction with single
or multilevel laminectomies. Fusions can also be performed form the front or
the back of the spine.
In select older patients, more rarely younger individuals,
non-instrumented lower back (lumbar) fusions may be required. Indications
include: (a) massive disc herniation (central), (b) arthritic slip in patient
with osteoporosis, (c) patient with cyst popping out of the facet joint
(synovial cyst), (d) other. These operations are most typically combined with
multilevel laminectomies in older osteoporotic patients and can be performed
over multiple levels. They utilize the patients own bone obtained from the
laminectomy. Patients are often braced for 3-4 months. CT scans and
Flexion/Extension X-rays are utilized to document fusion.
In patients with unstable lumbar spines, instrumented
fusions may be required. Indications for fusion are multiple: (a) disc excision
particularly in a younger patient resulting in instability, (b) removal of a
facet joint, (c) chronic slip in the bones (spondylolisthesis), (d) fracture in
the bone between the facet joints (spondylolysis), (e) other. Fusions performed
with laminectomy often utilize the bone harvested from the laminectomy
(autograft) site and do not typically require bone from the hip (iliac
autograft). These operations are performed with monitoring and fluoroscopy.
Patients usually wear a body brace from 3-4 months or until fused based on both
Flexion/Extension X-rays and CT scans.
Epstein
NE: Primary fusion for the management of “unstable” degenerative
spondylolisthesis. Neuro - Orthopedics (Spinger-Verlag),
23:45-52,1998
Epstein NE: Lumbar
Synovial Cysts: a review of diagnosis, surgical
management, and outcome assessment. J Spinal Disord Tech. 2004 Aug;17(4):321-5.
Plain
X-rays of the spine taken from the front (AP or anterior/posterior) or the side
(lateral) yield important information regarding the alignment of the spine.
Flexion and extension X-rays detail whether there is any abnormal motion
(instability) of the spine when the patient flexes forward or extends backward.
Identification
of spinal disease can be confirmed with both MR and CT studies. MR (Magnetic
Resonance Imaging) examinations do not involve radiation. They best document
the soft tissues (nerves, spinal cord) of the spine, and the soft-tissue
disease compressing the nerve tissue (discs, tumors). On the other hand, CT
scans better demonstrate bone detail such as arthritic changes, stenosis (narrowing
of the cervical spine), and calcified discs.
Epstein NE: From
Postsurgical Imaging: Marked superior and inferior migration of a dynamic plate
after multilevel anterior corpectomy and fusion with posterior wiring. The
Spine Journal 1: 226, 2001
Epstein NE: Computed
Tomography (CT) validating bony ingrowth into fibula strut
allograft: A criteron for fusion, The Spine Journal, 2: 129-133, 2002
J Spinal Disorders & Tech 16(3):
243-7, 2003
Epstein
NE, Rosenthal AD, Epstein JA, Hyman RA: Technical Note: “Dynamic” MRI
scanning of the cervical spine. Spine, 13(8):
937-938, 1988
The risk of neurological damage during operations on the
neck (cervical), mid back (thoracic), and lower back (lumbar spine) can be
minimized by utilizing intraoperative monitoring. Somatosensory Evoked
Responses (SSEPs) study the electrical potentials in the spinal cord from the
hands and feet, through the neck to the brain. If changes occur in these
potentials while putting the tube in the throat at the beginning of surgery
(intubation), during operative positioning, or during the operation itself,
adjustments to help protect the spinal cord can be made. The electrical
potentials of the nerves themselves (EMG’s) can also be monitored during
selected intervals of operations from the front or back of the spine.
Epstein NE: Somatosensory evoked
potential monitoring in cervical spine surgery. In Degenerative Disease of
the Cervical Spine, Neurosurgical Topics Book Series of the AANS, P Cooper
(ed), Robert Wilkins (pub), New York, Chapter 5: 49-72, 1992
Epstein NE, Danto J, Nardi D: Evaluation of intraoperative
somatosensory evoked potential (SSEP) monitoring during 100 cervical
operations. Spine, 18(6): 737-747,
1993
Epstein
NE: Somatosensory evoked potential monitoring (SSEPs) in 173 cervical
operations. Neuro-Orthopedics (Spring-Verlag),
20: 2-21, 1996
Epstein
NE: Impact of somatosensory evoked potential monitoring on outcomes in
cervical surgery. In Principles of Spinal Surgery, Benzel E (ed), McGraw
Hill (pub), New York, (in press)
Epstein
NE: Intraoperative monitoring for spine surgery (Part A): an aggressive
approach to monitoring. In Controversies in Spine Surgery, Benzel E, Zdeblick T, Anderson P, Stillerman
C (eds), Chapter 26 (in press)
In
conjunction with her colleagues in Anesthesia, Dr. Epstein utilizes “Bloodless
Spinal Surgery” in appropriate cases. This technique is particularly useful in
lower back (lumbar) surgery performed with or without fusion. It has proven
useful in patients whose religious beliefs don’t allow for the use of blood
products (i.e. Jehovah’s Witnesses). “Bloodless Surgery” can be utilized in the
majority of healthy individuals. Preoperative blood donation is avoided (with
its risks of infection, receiving the wrong unit, removal of coagulation
factors), along with its cost. At the beginning of surgery, the patient’s blood
is removed (1-2 units based on your preoperative blood level); patients are
given fluids to maintain a normal blood pressure. During the operation, less
blood (fewer red cells) is lost. At the end of surgery, the patient’s fresh
blood is returned. Most patients have not required additional blood
transfusions.
Epstein
NE,
Peller A, Boutros A, DeCrosta D, Schmigelski C, Greco J. "Bloodless" Lumbar Decompressions
with Instrumented Fusions: A Preliminary Report of 14 Cases. Winthrop
University Hospital Medical Journal, 2004
Epstein NE, Peller A, Koreff J, DeCrosta D, Boutros A, Schmigelski,
C, Greco J: Normovolemic
Hemodilution: An Effective Method for Limiting Postoperative Transfusion
Following Complex Lumbar Spinal Decompression with
Instrumented Fusion. Spinal Surgery 18(3):179-188, 2004
Dr. Epstein has recently studied whether artificial bone can
be used to expand and supplement bone taken from the patients themselves
(autograft) during different types of procedures. Beta Tricalcium Phosphate
appears to be just such a promising bone expander.
Epstein
NE: Efficacy of Combined Beta Tricalcium Phosphate in Anterior Iliac Crest
Reconstruction with MacroPore Sheet. Spinal Surgery (in press 2005)
