SPINE SURGERY

Surgeries performed with the highest neurological safety standards using technology and expertise in spinal neuronavigation, intraoperative O-Arm (CT), and intraoperative monitoring. Minimally invasive procedures: microsurgery and spinal endoscopy.

The most notable pathologies treated are:

  • Degenerative pathologies: spinal canal and foraminal stenosis
  • Posterior spinal arthrodesis (TLIF), lateral arthrodesis (XLIF), anterior arthrodesis (ALIF), and combined arthrodesis
  • Disc replacement (intervertebral disc prosthesis)
  • Spinal deformity and sagittal balance pathologies
  • Spinal oncology
  • Skeletal pathologies (bone tumors, bone metastases, etc.)
  • Surgery for spinal cord tumors (astrocytomas, ependymomas, etc.) and intradural tumors (schwannomas, meningiomas, etc.), cavernomas, etc.
  • Adolescent scoliosis. Surgeries with 3D spinal guides; anterior surgeries
  • Treatment of traumatic spinal cord injuries with stem cells

 

LUMBAR DISC HERNIA

The appearance of a herniated lumbar vertebral disc can lead to pain in the lower back, called low back pain or lumbago, as well as discomfort radiating to the lower extremity, called sciatica. Sciatica is the most characteristic symptom of a herniated disc, and the distribution of pain varies depending on the compressed nerve root or nerve.

Most patients improve with conservative treatment. This type of therapy consists of rest, analgesics and anti-inflammatories, injections, etc.

However, surgery is necessary in more than 5% of cases, reaching up to 10% of those affected.

Therefore, surgery should be the final option, only recommended if the patient cannot tolerate the pain after 6 to 8 weeks of conservative treatment or if they experience progressive loss of strength or sphincter problems.

If the herniation is large and compresses all the nerves it encounters, it can cause what is called cauda equina syndrome, which is a surgical emergency.

In most cases, this pain resolves with conservative treatment without surgery. However, approximately 10% of cases will require surgery.

Discectomy is the best technique for treating herniated discs.

If there is no improvement with conservative treatment, after a reasonable period of time (which varies depending on the intensity of the pain and the response to medication), surgical treatment is performed. This consists of removing the herniated disc (discectomy).

If the patient has had frequent episodes of lower back pain prior to the onset of the herniated disc, a spinal fusion is associated with it.

In the cervical spine, this spinal fusion is associated with it in most cases.

NON-INVASIVE PERCUTANEOUS TECHNIQUES FOR HERNIATED DISC

There are other treatments that are performed without opening or with minimal incisions.

These include percutaneous nucleotomy, laser nucleotomy (laser coagulation of the disc), and chymopapain chemonucleolysis (chemical dissolution of the center of the disc through an injection of this substance).

These techniques, which can only achieve good results when indicated correctly, are recommended in a small number of cases, when the disc contents have not completely extruded from the wall and the nerve is compressed.

 

CERVICAL DISC HERNIA

A cervical disc herniation is a condition in which the nucleus pulposus of the intervertebral disc herniates into the spinal canal, compressing nerve structures and causing pain and other symptoms such as:

  • Persistent neck pain that does not respond to conservative treatment.
  • Compression of nerve roots causing weakness, numbness, or tingling in the arms and hands.
  • Loss of bladder or bowel control due to spinal cord compression (myelopathy).
  • Difficulty walking or ambulation, leg weakness.

 

ADVANTAGES OF ANTERIOR DISCECTOMY AND MINIMALLY INVASIVE FUSION:

Reduced trauma: By accessing the cervical disc through a small incision in the neck, damage to surrounding tissues is minimized, leading to faster recovery and less postoperative pain. Greater precision: Advanced imaging and navigation techniques allow for detailed visualization of the cervical spine, facilitating more precise and safe surgery.

Restored stability: Bone fusion between adjacent vertebrae helps restore stability to the cervical spine and prevent cervical hernia recurrence.

Preserve mobility: We aim to preserve maximum mobility, allowing for a rapid recovery.

Most patients spend only 24 hours in the hospital after surgery and go home without a neck brace, able to resume normal activities with rapid recovery and full mobility.

 

Spinal Stenosis

Spinal stenosis occurs when the spinal canal narrows and puts pressure on the spinal cord and/or nerve roots.

The spinal cord is a part of the central nervous system that extends from the base of the brainstem and runs through the spinal canal. Narrowing of the spinal canal, through which the spinal cord and spinal nerves pass, usually occurs in older age and involves one or more areas of the spine.

Depending on the affected area of ​​the spine, spinal stenosis can be classified as:

Lumbar spinal stenosis: Located in the lower part of the spinal column, between the L1-L5 vertebrae. It can present in different forms, such as low back pain, radiculopathy, or leg weakness, for example. Symptoms are usually relieved by bending the trunk while standing or sitting. It is a degenerative and, in most cases, slowly progressive condition. Cervical canal stenosis: Narrowing of the canal occurs in the upper part of the spine, between the C1 and C7 vertebrae. Symptoms include neck pain and stiffness, numbness and tingling, loss of strength in the arms and hands, loss of balance, and dizziness.

The causes of spinal canal stenosis can be classified into three groups: degenerative, due to alterations in the spinal tissues caused by natural degenerative processes; congenital, present from birth due to alterations in the spinal tissues during embryonic development; and traumatic, due to an injury or trauma that causes alterations in the spinal tissues. There may also be other causes, such as tumors, among others.

One of the main goals of lumbar or cervical stenosis surgery is to decompress the spinal cord and/or nerve roots. By giving them more space, nerve swelling will decrease, as will pain. The operation is also expected to increase motor strength in the extremities. Surgeons typically use two surgical techniques for spinal stenosis surgery: decompression, in which the surgeon removes tissue pressing against a nerve structure and creates more space in the spinal canal or the foramen where the nerve exits; and stabilization, to limit movement between the vertebrae, for example, in cases of vertebral listhesis.

To remove the tissue pressing on the nerve, the surgeon will perform one of these types of surgery:

Decompressive laminectomy. This is the most common procedure and can be a lumbar laminectomy or a cervical laminectomy. It removes the posterior portion of the affected spinal bone, relieving pressure on the nerves by creating more space around them.

Hemilaminectomy. This is indicated for patients with symptoms and unilateral stenosis. It resects the lamina on the affected side and preserves the integrity of the interspinous and supraspinous ligaments, minimizing spinal instability.

Discectomy and fusion. Sometimes, disc degeneration plays a key role in narrowing the intervertebral foramen and causing spinal stenosis. In these cases, it may be necessary to restore the collapsed disc space by removing the degenerated disc and fusing the adjacent vertebrae.

Typically, the patient will be able to walk the day after surgery and will be discharged within 48 hours.

 

KYPHOPLASTY FOR VERTEBRAL FRACTURES

Kyphoplasty is the fastest and safest method for relieving pain in vertebral fractures, restoring vertebral height, and preventing the possibility of fractures due to osteoporosis in adjacent vertebrae.

Kyphoplasty is performed using minimally invasive surgery with two incisions, each only 3 millimeters long, parallel to the spine. The patient can walk the same day and does not require a brace or bed rest. It can be performed under local anesthesia.

Kyphoplasty is much safer than vertebroplasty because a space is created in the fractured vertebra with an inflatable balloon that restores vertebral height and is filled with plastic cement injected at low pressure.

In vertebroplasty, the space is not created with a balloon and the cement is injected at high pressure, which carries the risk of invading the spinal canal, blood vessels, and other surrounding tissues, and does not restore vertebral submergence.

Kyphoplasty is the most modern and safe method for improving the quality of life of people suffering from vertebral fractures.

 

RESECTION (CORPECTOMY) AND VERTEBRAL RECONSTRUCTION OF COMPLEX AND COMMINUTE VERTEBRAL FRACTURES

In the most severe fractures, comminuted and burst fractures, a vertebral body fragment may have displaced into the spinal canal, causing compression of the neurological structures (spinal canal stenosis).

In cases with neurological compromise, partial or total resection of the fractured vertebral body (corpectomy) is required, followed by reconstruction using an expandable somatic cage. Reconstruction is usually completed with an instrumented and cemented percutaneous arthrodesis of the levels adjacent to the fracture. The resection (corpectomy) allows the vertebral fragment located in the spinal canal to be removed and the affected neurological structures to be released. Reconstruction using a somatic cage relieves the patient’s load on the fracture and relieves the pain it causes.

 

MINIMALLY INVASIVE DYNAMIC SCOLIOSIS CORRECTION (ASC/VBT)

A new technology has recently been developed for the surgical treatment of scoliosis called anterior scoliosis correction (ASC), also known as vertebral body tethering (VBT).

This technique uses a cord (a biocompatible braided plastic composite) to dynamically join the vertebral bodies of the spine and correct scoliosis. This technique eliminates the need for the rigid metal/titanium rods used in traditional surgery, preventing the child’s spine from becoming rigid and unable to bend after surgery.

This innovative surgical technique maintains spinal flexibility and movement, modulating the harmonious growth of the vertebral bodies, allowing the patient’s trunk to develop naturally and ultimately reach a normal size for their age and growth. Furthermore, harmonious growth means that the scoliosis curve even continues to improve as the child grows with age.

Another major advantage of the anterior approach correction technique (ASC/VBT) is that it is reversible, as it does not induce bone fusion of the patient’s spine (which would be irreversible). Therefore, if the patient’s progress is unfavorable, traditional surgical techniques can always be used without any inconvenience to the patient.

This surgical technique is performed using a minimally invasive approach through the patient’s ribs (anterior approach to the thorax or mini-thoracotomy) assisted by thoracoscopy. Similar to a spinal endoscope, the thoracoscope provides visualization of the anatomical area being operated on using a high-definition camera. High-quality image visualization allows for highly precise surgery with minimal risk of injury to the patient. ASC/VBT surgery is performed using a minimally invasive approach, and therefore, patient recovery is very rapid. Patients are discharged from the hospital four days after surgery (barring complications). The surgical incisions are small, allowing for rapid recovery with minimal postoperative pain.

The best patients for this anterior correction technique (ASC/VBT) are children and adolescents between 9 and 16 years of age with approximately 2-3 years of growth remaining, with scoliosis angles of less than 65°, and a spine that is still flexible.

 

BRAIN TUMOR

Modern neurosurgery achieves, in most cases, the removal of tumors without causing additional neurological damage to the patient, with improvement of existing lesions, in diseases such as:

  • Glioblastoma
  • Meningioma
  • Brain metastasis
  • Pituitary adenoma
  • Craniopharyngioma
  • CNS lymphoma
  • Schwannoma
  • Paraneoplastic neurological syndrome
  • Spinal cord tumors
  • Neuronal tumor

 

VASCULAR NEUROSURGERY

For the most important pathologies: aneurysms, AVMs, cavernous angiomas, arteriovenous fistulas.

  • Endovascular procedures. Sessions with vascular experts to discuss the optimal therapeutic strategy.
  • Radiosurgery available with linear accelerator, gamma knife, cyber knife, and protons.
  • Extensive experience in vascular microsurgery and multidisciplinary committees for cerebrovascular and spinal vascular surgery.

• Advanced treatment of cavernous angiomas: laser (Visualase) and in areas of high functional eloquence: brainstem, basal ganglia, language, and sensory-motor areas; minimization of epileptic seizures after surgery with corticography-guided resection.

PEDIATRIC NEUROSURGERY. (Patients over 40 kg)

  • Tethered spinal cord, spinal lipomas
  • CSF disorders, Chiari (pediatric and adult), syringomyelia, arachnoid cysts…

 

PAROTID TUMOR

After diagnosis, the tumor is staged to determine its extent and whether it has spread to lymph nodes or other areas. Staging is crucial in determining the appropriate treatment.

Treatment may vary depending on the type of tumor and its nature (benign or malignant). However, the most common approach is surgery to remove the tumor and, in some cases, complementary radiation therapy to eliminate residual cancer cells. Drug treatment is usually considered in more advanced cases or if the tumor is inoperable.

Treatment is customized to each patient’s needs and based on the recommendations of the medical team after a complete evaluation.

The main treatment for parotid tumors (benign and malignant) is surgery, as it allows for the removal of the tumor and, in many cases, provides a definitive diagnosis. The type of surgery performed depends on the type of tumor, its size, location, and its nature (benign or malignant).

Extended lumpectomy. It is performed with the assistance of a neurostimulator that locates and alerts when working near the facial nerve. If the tumors are very peripheral, the tumor is removed without dissecting the entire facial nerve.

Superficial parotidectomy. Removal of a portion of the parotid gland. It is performed when the tumor is located on the superficial part (superficial lobe) of the gland, and the portion above the facial nerve is removed. The goal is to preserve the function of the gland and the facial nerve.

Total parotidectomy. Removal of the entire parotid gland. When the tumor is malignant, large, or in a position that makes partial removal inappropriate, the affected parotid gland is removed. The goal is to preserve the facial nerve to minimize changes in facial function, but this may vary depending on the extent of the tumor.

Radical parotidectomy. Radical removal. This procedure is performed in cases of advanced malignant tumors that have spread to nearby structures, such as nerves or lymph nodes. It involves the removal of the parotid gland (with the facial nerve within it), regional lymph nodes, and other affected structures.

Reconstructive techniques. In some cases, especially after a total or radical parotidectomy, reconstructive surgery may be performed (immediately or delayed) to restore facial function and appearance. This may involve tissue transfer, such as a nerve or muscle graft (reconstructive microsurgery), to restore facial nerve function, or static techniques that achieve facial symmetry, cosmeticize facial features, and reduce functional impact.

It is important to note that the choice of the specific surgical procedure depends on the medical team’s evaluation of the tumor and careful planning to minimize side effects and complications. Parotid surgery should be performed by a surgeon experienced in maxillofacial or head and neck surgery with reconstructive expertise, as preservation of the facial nerves and facial function is crucial.

After surgery, radiation therapy or facial rehabilitation therapy may be required to achieve a full recovery and minimize cosmetic and functional consequences.

 

PITUITARY GLAND TUMOR

The first line of treatment for pituitary gland tumors is usually surgery. This is indicated in cases of macroadenoma (a tumor larger than 1 cm), when it compresses the optic tract, or when hormonal testing reveals excessive production (as is the case with GH and ACTH production in acromegaly and Cushing’s disease, respectively). However, prolactinoma, a prolactin-secreting tumor and the most common functioning pituitary gland tumor, is a secretory tumor that is usually treated medically without the need for surgery except in special cases.

Pituitary gland surgery consists of removing the tumor while leaving healthy glandular tissue intact. Pituitary gland surgery has improved significantly in recent years thanks to the transsphenoidal approach, which involves removing the tumor through an incision at the level of the nose, entering through the sphenoid sinus (cavity located behind the nose).

Traditionally, surgery was performed through a craniotomy (transcranial approach), in which the skull was opened to enter and remove the tumor. Currently, this technique is only performed in exceptional cases where the transsphenoidal approach is not possible.

To view the surgical area through the transsphenoidal approach, a surgical microscope or a fiberoptic endoscope is used, allowing for a minimally invasive approach to the pituitary gland.

The benefits of this technique compared to the traditional technique directly impact the patient, with a significant reduction in local complications, a shorter surgical time, increased patient comfort (absence of postoperative nasal packing and decreased postoperative pain), and a reduction in the average hospital stay, which can be as little as 24–48 hours.

In many cases, the entire tumor can be removed, preserving healthy tissue. However, in other cases, the tumor is very large and can invade neighboring structures, leaving tumor remnants or removing part of the healthy tissue. This can lead to deficiencies of certain pituitary hormones. In this case, medical treatment is necessary to correct these deficiencies.

In general, intensive care is not required after surgery. Headache, nasal congestion, a mild loss of taste and smell, which disappears in the following days, and fatigue, which usually improves within a few days, are common.

In the case of pituitary tumors, radiation therapy is used when the tumor persists, grows, or recurs after surgery, when surgery cannot be performed due to contraindications or a low probability of success.

 

PARKINSON’S DISEASE

Parkinson’s disease surgery is indicated when drug treatment fails to control the patient’s symptoms throughout the day.

It is performed with deep brain stimulation (DBS). To achieve this, high-frequency stimulation is applied to a small part of the brain called the subthalamic nucleus by placing electrodes. Electrical impulses inhibit the overactive part of the brain that causes the disease.

Parkinson’s disease currently has no cure, but the benefits obtained through surgery are clear: it achieves a setback equivalent to years of progression. Specifically, there are improvements in movement, as well as a reduction in rigidity and tremors in patients.

It also allows for medication reduction, which avoids the psychiatric side effects of medications.

Surgery is performed on patients who do not tolerate drug treatment well or find it ineffective, as well as on those for whom the disease is particularly disabling.

Surgical success depends on the selection of the candidate, proper placement of the electrode in the brain, and proper stimulation and medication.

The first step is a brain MRI, the images of which are subsequently used by neuronavigation software. The MRI is used to calculate the coordinates of the area where the stimulating electrodes will be inserted.

A small incision is made in the scalp, and then a hole approximately 1 cm long is opened in the skull (stereotaxy). Thanks to the guidance provided by an electrophysiological recording of neuronal activity, the exact location for the electrical stimulator is located.

The procedure is performed under local anesthesia, and the patient is conscious during the procedure, allowing them to collaborate with the surgical team to assess the effect of the stimulation before the final implantation of the electrode.

The second part of the treatment takes place a few days later under general anesthesia and involves placing the connecting cables and the pacemaker or battery that supplies the electrical stimulation under the skin. Typically, the pacemaker is inserted under the collarbone.

 

ESSENTIAL TREMOR

WHAT IS HIFU?

High-intensity focused ultrasound (HIFU) is used to treat patients with essential tremor and the tremor, rigidity, and clumsiness that occur in Parkinson’s disease.

In the vast majority of cases, the tremor improves immediately, an effect that the patient benefits from in a single session.

As it is a noninvasive procedure, no prior hospitalization is required, and the patient is discharged within 24 hours after the session. As with any treatment, side effects may occur, which, in most cases, usually resolve within a few weeks.

A month later, the patient will return for a follow-up visit, and at that point, the follow-up care required by specialists will be determined.

This technique is used to treat essential tremor and Parkinson’s tremor and is also used to treat other Parkinson’s symptoms such as rigidity and slowness.

The patient should be evaluated in consultation by a neurologist to determine whether or not they are a candidate for this procedure.

The procedure is applied unilaterally, so the benefit is achieved on the most affected side of the body.

Generally speaking, potential candidates include:

  • Patients whose tremor and other symptoms respond partially to treatment.
  • Patients who, due to their health, age, etc., are not candidates for surgery.

HIFU is performed like a magnifying glass in which the sun’s rays converge to concentrate the heat on a single point. This is how high-intensity focused ultrasound (HIFU) equipment works. This technology captures the heat from thousands of ultrasounds beams and concentrates them on a target: the group of neurons involved in the tremor.

This is a noninvasive procedure that does not require an operating room; rather, it is performed in the MRI examination room. The patient is awake and only has a stereotactic frame placed on the head and a silicone membrane containing water to cool the skin and prevent damage.

Once the surgical target is located on the MRI, the neurosurgeon begins applying ultrasound, which will be increased in intensity depending on the patient’s improvement until the maximum possible effect is achieved.

Depending on the patient’s progress, an MRI will be performed after a few months.

 

EPILEPSY

Epilepsy surgery requires a multidisciplinary team. The selection of the surgical candidate, as well as the preoperative evaluation with video-EEG monitoring, functional MRI, and even invasive monitoring, are key aspects in predicting the success of the surgery, as they identify the epileptogenic lesion area.

The most frequently used surgery is hippocampectomy (removal of the temporal pole below the first temporal gyrus) and subpial excision of the hippocampus, entorhinal cortex, and amygdala. These procedures can be approximately 3 cm in length.

Surgical outcomes are validated by scales and by the reduction of antiepileptic medication.

Among the types of epilepsy, temporal lobe epilepsy is the most common, and it is the only curable type.

Drug treatment controls 80% of patients with temporal lobe seizures, but the rest do not respond to various antiepileptic treatments for which drugs are prescribed.

The remaining patients (20%) who do not respond to drugs are candidates for surgery. Of these, 75% can improve with surgery.

Surgery involves removing a portion of brain tissue, with or without a visible lesion, related to the cause of the epileptic seizures. These are focal seizures. They most often respond very well to surgical treatment.

 

HYDROCEPHALUS

Ventriculoperitoneal shunt (VPS) is a surgical procedure performed to drain excess fluid accumulation within the cranial cavity (hydrocephalus).

This accumulation of cerebrospinal fluid (CSF) causes dilation of the brain’s cavities (ventricles), thereby exerting increased pressure on brain tissue. This, if not treated immediately, could cause irreparable damage to brain function.

Hydrocephalus is primarily the result of an imbalance between the levels of fluid produced (CSF) surrounding the brain and the levels of fluid absorbed. This is triggered by conditions that cause obstruction at fluid absorption sites, excess production, or bleeding. This imbalance can occur at any age, but it is most common in newborns and adults over 60-65 years of age. Its origin can be congenital or acquired:

Congenital: present at birth as a result of:

  • Genetic problems
  • Congenital spinal defects (spina bifida)
  • Infections during pregnancy
  • Pathologies that occur during childbirth

Acquired: develops as a result of:

  • Tumors (brain tumors)
  • Infections (meningitis)
  • Cerebral hemorrhage (bleeding)
  • Post-cranial surgery
  • Unknown origin
  • Accidents
  • Head trauma

The objective of ventriculoperitoneal shunting (VPS) is to remove excess fluid accumulated inside the skull to the abdominal region (peritoneum) by implanting a catheter (tube + valve). will be used in the regulation and drainage of said liquid.

 

TRIGEMINAL NEURALGIA

Trigeminal neuralgia is a special type of facial pain, highly intense and requiring specialized treatment. In some cases, neurosurgery is necessary to overcome the bothersome symptoms caused by irritation of the cranial nerve, the trigeminal nerve.

When normal causes of trigeminal pain (facial pain, especially dental conditions such as cavities, abscesses, infections of the mouth or facial bones, complicated wounds, and others) have been ruled out, the pain is generally due to minor deformities or malpositions of certain small blood vessels (arteries or veins) that may touch this nerve as it passes through the base of the skull. These blood vessels are normal; in other words, they are not generally a malformation or unnecessary vessels; they are simply slightly different positions that trigger the symptoms. With the normal pulsation of the arteries, the nerve interprets the stimulus as intense pain and then generates the symptoms of facial pain. Other times, less frequently, tumors or infections will be found that cause pain through direct contact with the nerve, but these cases are not grouped within the primary trigeminal neuralgia we are referring to here.

It always involves stabbing pain on one side of the face that can radiate toward the ear canal. It is usually triggered by a normal stimulus to the face (for example, cold or heat, speaking, eating, touching certain areas, smiling, sneezing or coughing, etc.). The intensity of the pain varies and can range from tolerable, moderate pain to the most intense pain that humans can suffer. When the pain is very severe, one faces the classic picture of trigeminal neuralgia, as the patient is limited and unable to perform certain basic activities normally (eating, speaking, etc.) due to the great fear of experiencing the pain again.

Anyone can suffer from trigeminal neuralgia. Generally, but not always, it occurs after the age of 50. When there are no normal factors that cause the pain (such as dental problems), there is no predisposition to this pain due to other personal or family medical conditions. It is important to emphasize that dental disease should always be ruled out before making this diagnosis, as the pains are similar and are often confused.

There are several therapeutic options for trigeminal neuralgia.

Open surgery is indicated when a normal vessel in the brain is compressing the nerve. Therefore, the surgery aims to separate this vessel and insert a material that prevents the vessel’s pulse from transmitting to the nerve. This is done through a small opening behind the ear bone on the painful side of the face (retromastoid craniotomy).

This procedure is primarily indicated for young patients.

Another alternative is to burn (thermocoagulation) the part of the nerve trunk corresponding to the painful area of ​​the face (Gasserian ganglion) with radiofrequency (an ablative technique). This procedure effectively renders the face numb. This procedure can work for years, although pain may recur.

This procedure is indicated for older patients or those with conditions that preclude the first option. It is performed under deep sedation.

And the last alternative is to modify the nerve’s function with radiosurgery. It is indicated when there is no vessel compressing the trigeminal nerve or in patients with significant pathologies or advanced age.

This procedure does not produce immediate results; it can take weeks or months for the pain to improve. Relapse may also occur with the pain returning, at which point the treatment can be repeated.

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