The patient
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Brief anatomical and functional introduction
By dr. Roberto Bassani
The vertebral column in humans is a complex structure consisting of 24 single vertebrae plus the sacrum.
The main functions are:
Protect the spinal cord that is inside it.
Provide for trunk mobility and transfer load forces from the head through the trunk to the pelvis, then to the lower limbs.
Thanks to the natural and physiological curves (cervical lordosis, dorsal kyphosis and lumbar lordosis) and the interposition of the relatively elastic interverterbal disks (when integral) between the rigid vertebrae, the spine becomes a structure capable of filtering and cushioning traumas before they arrive to the head (and therefore to the brain).
The intrinsic stability of the spine is guaranteed by the vertebral discs and the ligaments that join the vertebrae together, supported by the powerful action of the muscle groups that are inserted into the column itself. It is evident that only the integrity of all these components (discs, ligaments and muscles) guarantees the efficiency of the functions of the spine and therefore the absence of pathologies and ultimately the absence of pain.
The spine can be divided into four distinct regions: cervical, thoracic, lumbar and sacral.
The cervical and lumbar ones are of great clinical interest as, due to their high mobility, they are particularly subject to traumatic episodes and wear. When we speak generically of lumbar or cervical arthrosis we refer in fact to a heterogeneous group of pathologies related to the wear of some structures (vertebral disc, posterior joints of the vertebrae) that produce permanent alterations of the functions of the spine.
Intervertebral disc degeneration is an expected and natural event (aging).
It often occurs silently and asymptomatically. Sometimes, however, there are situations in which this degenerative process compromises the stability of the lumbar spine, producing an initial condition of hypermobility due to chronic inflammation and therefore pain.
Despite various population studies, it is not yet clear what is the initial cause of the physiological aging process of the motion segment (disc and joints) of the spine. In particular at the lumbar level, it is common opinion that the evolution of the degenerative process originates from an initial alteration of the disc that subsequently involves other structures.
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There are three evolutionary stages of degeneration:
In the first stage (between 20 and 30 years) biochemical and mechanical alterations of the disc already create a dysfunction of the movement (joint kinematics) during the normal stresses of the spine.
In the second stage (between 30-60 years) there is a progression of degenerative phenomena and the disc thins. The distribution of loads (remember that one of the main functions of the column is to distribute the loads in a balanced way!) Changes. The posterior joints of the vertebrae are also overloaded and worn out. These alterations can become definitive and lead to symptomatic instability produced by the movements and posture of the trunk.
Subsequently in the third stage (over 60 years) , the disc thins further and the degeneration of the posterior joints of the vertebrae (arthrosis) are such that the spine stiffens definitively losing the ability to absorb loads. In this phase, which is not always more painful than the second (instability), you can also see real deformities (severe kyphosis, degenerative scoliosis or lateral imbalances) or narrowing (stenosis) of the vertebral canal with compressions of the nerve roots that occur with annoying lumbosciatica (back pain radiating to the lower limbs).
These processes normally take place along the various stages of life but, due to different stresses, genetic predisposition, traumas or previous interventions on the spine, they can be observed more and more in young individuals causing important disabilities.
New frontiers for surgery
With the aging of the population and the sedentary lifestyle, the number of individuals suffering from spinal cord disorders has also increased.
After the age of 45, 50 percent of Italians suffer from back pain several times a year. Low back pain, lumbosciatica due to herniated disc or degenerative stenosis are very frequent, which also lead to pain in the legs and feet due to the involvement of the sciatic nerve. The degenerative process, as we have seen, compromises the stability of the lumbar spine, producing a condition of hypermobility which causes chronic inflammation and therefore pain. A sedentary lifestyle and being overweight certainly do not contribute to a high functionality of our organism.
Lifestyle, weight control and physical activity are essential to effectively combat and prevent the loss of mobility. When anatomical integrity fails (due to inevitable degenerative phenomena) it is even more important to act on what is still possible to influence with will and constancy: muscle tone and weight reduction!
In the case of the cervical or lumbar spine (the most mobile segments and therefore more subjected to wear), an incorrect position during sleep or work, or a slight trauma in a subject already predisposed to alter its natural functionality, is sufficient. Symptoms are variable: a feeling of "stuck" neck or back. Sometimes, on the other hand, acute and persistent pain affecting the arm and forearm, up to the hand (for cervical hernias) or some areas of the leg and foot (sciatica) for lumbar hernias.
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Where these symptoms become chronic, are caused by permanent alterations of the intervertebral disc or posterior joints (severe degeneration), and conservative therapy (anti-inflammatory, rest and physiotherapy) is not effective, excellent results can be obtained with surgery (traditional or minimally invasive ). In particular, the minimally invasive anterior approach to the vertebral column allows to treat pathologies of the lumbar vertebral disc through small incisions on the anterior wall of the abdomen (generally around the navel, original technique described by the author) so as to reach, through the use of endoscopic instruments, the “degenerated” disc and remove it by performing a minimally invasive anterior arthrodesis. This procedure has the enormous advantage of not “dissecting” the muscles of the posterior column and therefore allowing a very fast functional recovery.
Vertebral surgery has certainly had an extraordinary development in recent years. Advances in implant and instrument technologies, minivasive surgery through the experimentation of new anterior and lateral "anatomical pathways", the computer-assisted one, are the factors of this success. The possibilities of treating herniated discs, vertebral fractures, scoliosis, kyphosis, spondylolisthesis, discopathies, infections and tumors have multiplied through less invasive methods that were previously unthinkable.
However, it is necessary to keep in mind that surgery can do a lot, but not always. In any case, it must be the last step in a conservative process suited to the problem and to the patient's quality of life.
Many patients have excessive expectations!
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A certain number of patients (up to 30%) undergoing spinal arthrodesis surgery had to resort to surgery again for "mechanical" problems as a result of degeneration of adjacent discs with new discomfort and pain. This risk increases in elderly patients. Only an adequate evaluation of expert surgeons can evaluate in relation to the pathology and the patient's condition whether there is the possibility of intervening adequately by evaluating the risks and benefits to give a real improvement in the quality of life.
Knowledge of spine biomechanics and advances in implant and instrumentation technologies have allowed the development of new techniques to treat back and neck problems by reducing failures.
In fact, in the vertebral surgery department of the Galeazzi Institute in Milan, many complex patients are treated due to the failure of previous surgeries. This occurs through combinations of traditional and minimally invasive techniques with instruments at the forefront with the ultimate aim of improving the quality of life.
The most surprising result of the application of these new methods (minimally invasive surgery when possible) is the speed with which the patient can return to life as usual. He can get up on the same day or the next and is able to resume all his normal activities within a few weeks. It is therefore a big step forward in solving these problems that afflict tens of thousands of adults and which represent one of the major causes of disability and absence from work. Furthermore, by reducing the use of painkillers, anti-inflammatories and hospitalizations, they also allow considerable savings for the national health system.
Italy it is undoubtedly one of the most advanced from this point of view, but this type of vertebral surgery is still not very widespread and is present only in some reference centers.
The Galeazzi Institute of Milan is a center of excellence for vertebral surgery recognized all over the world.
The Vertebral Surgery II team directed by dr. Roberto Bassani is also one of the operational units of the IRCCS Galeazzi Orthopedic Institute which made it possible to obtain in 2019 the certification of Excellence as a Center for Spinal Surgery at European level by Eurospine, the vertebral surgery company of reference for the guidelines of the best European centers in the sector.
CLINICAL ACTIVITY OF THE DIVISION OF VERTEBRAL SURGERY
The Division headed by Prof. Bassani is the seat training for orthopedics and traumatology specialists of the University of Milan for spinal pathologies.
The clinical cases of the week are discussed collectively before the start of the operating session (from 7.15 to 7.45), with multimedia presentations for planning the surgical strategy.
Within the unit, scientific meetings are periodically held for medical specialists and in external specialized training (Orthopedics and Traumatology, Neurosurgery), aimed at clinical-surgical training :
acquisition of the biomechanical principles of sagittal balance of the spine
theoretical-practical demonstration of the minimally invasive techniques adopted by the team
management of complex clinical cases and management of the main surgical complications
