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Five in ten Canadians suffer from lower back pain (LBP) at some point in their life (Cowan et al., 2018). LBP prevalence ranges from 58-65% across studies in Canada, the United States, Europe and South America (Schopflocher et al., 2011). Furthermore, Atlas et al. (2001) showed that LBP is the 5th leading diagnosis for all doctor visits with lower back being the most common site of chronic pain (Schopflocher et al., 2011). Common treatments for acute LBP include medication, exercise, or therapy (i.e. physiotherapy, acupuncture, massage therapy, chiropractor). Spine surgery may be recommended when other nonsurgical treatments do not provide relief.
If you are experiencing involuntary spasms or aches in your lower back, in addition to numbness, burning, or tingling down your leg, you might be suffering from LBP or commonly referred to as sciatica, which is pain in the back radiating into the leg.
Lumbar radiculopathy is one of the most common conditions associated with LBP. It is a leading cause of disability and often a reason for patients to undergo spine surgery. Traditionally, spine surgery is done as “open surgery”. However, spine surgery has transformed significantly through technological advancements and new approaches such as minimally invasive spine surgery (MISS). MISS eliminates the need for a long incision which avoids damaging surrounding muscle and instead, results in less pain post-surgery, faster recovery, and decreased blood loss.
In Atlantic Canada, Orthopaedic surgeons and Neurosurgeons have honed the MISS technique. Yet some approaches used internationally have not yet made their way into Canada. Dr. Najmedden Attabib, Neurosurgeon at Horizon Health Network and Assistant Professor at Dalhousie University emphasized the importance of technological advancements and MISS procedures. He added his perspective of the unmet needs for neurosurgical care lacking in Canada. Attabib’s interests include innovative minimally invasive techniques, cervical spine trauma, spinal cord tumours, spinal motion preservation, and spinal cord injury. MISS techniques continue to evolve, now introducing Endoscopic Spine Surgery (ESS), a small navigated camera to access the problematic area of the spine through a less than 1 cm incision. After approval from Health Canada, the first endoscopic spine surgery in Canada was performed in July of 2019 at the Saint John Regional Hospital (SJRH) by Dr. Attabib. Attabib mentioned that ESS is not used widely in North America, as neurosurgeons adopted the MISS method instead. Attabib was determined to bring this approach to Atlantic Canada after he attended two training sessions in Spain and France. He has since been getting patients ready for ESS. Patients are able to go home on the same day, with faster recovery and return to work faster. He was also the first to perform a series of interlaminar endoscopic discectomy cases in Canada improving patient recovery time.
The rise of minimally invasive procedures complements another current trend, which is the increasing popularity of off-site outpatient surgical centers. MISS allows surgeons to now treat the majority of common spine procedures as outpatient cases and also drastically continues to reduce the time needed to perform each procedure. This allows providers to see more patients per day, helping offset wait times. There is no widely adopted criteria for the priori estimation of sample size with this approach.
Dr. Najmedden Attabib, Neurosurgeon at the Saint John Regional - Approved by Dr. Najmedden Attabib
Research
Attabib is also involved in extensive research as one of the Neurosurgeons at Canada East Spine Centre and he is the Principle Investigator for Praxis Spinal Cord Injury Institute at SJRH. “The importance of research in the medical field is crucial because it is what drives medical care,” Attabib said. One of his most recent research projects was a collaboration across the country which explored Traumatic Cauda Equina Injury (TCEI), a relatively rare condition. The research team was inspired to look into TCEI as the limited amount of currently available information pertaining to this injury made it challenging to answer questions on this diagnosis. The research team had the goal of improving the ability to predict patient outcomes to better inform patients and their families on TCEI. Published in November 2020 (https://www.liebertpub.com/doi/full/10.1089/neu.2020.7303), patients with TCEI were found to have a one quarter chance of achieving full independence of bowel and bladder function. The significant impact of bowel and bladder outcomes on patient quality of life underlines the importance of finding predictors and managing expectations associated for all spinal cord injury patients.
The growing innovation in spine surgery and cost-effective technology represents an opportunity to achieve the goal of making surgical care more accessible and improving patient quality of life. The future is bright for new, improved methods of spinal surgery. Other technological and biological advances are on the horizon that will work in concert with minimally invasive techniques. Computer-assisted image-guided technology, bioresorbable, flexible and radiolucent spinal implants, and genetic-engineering of disc tissue, and other advancements, are worthy of discussion and implementation.
References
Atlas, S. J., & Deyo, R. A. (2001). Evaluating and Managing Acute Low Back Pain in the Primary Care Setting. Journal of General Internal Medicine, 16(2), 120–131. https://doi.org/10.1111/j.1525-1497.2001.91141.x
Cowan, A. J., Allen, C., Barac, A., Basaleem, H., Bensenor, I., Curado, M. P., Foreman, K., Gupta, R., Harvey, J., Hosgood, H. D., Jakovljevic, M., Khader, Y., Linn, S., Lad, D., Mantovani, L., Nong, V. M., Mokdad, A., Naghavi, M., Postma, M., … Fitzmaurice, C. (2018). Global burden of multiple myeloma: A systematic analysis for the global burden of disease study 2016. JAMA Oncology, 4(9), 1221–1227. https://doi.org/10.1001/jamaoncol.2018.2128
Schopflocher, D., Taenzer, P., & Jovey, R. (2011). The prevalence of chronic pain in Canada. Pain Research & Management : The Journal of the Canadian Pain Society, 16(6), 445–450.
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