Medical Minute 7-20: Spinal Surgery Made Easy

By: Vanessa Welch Email
By: Vanessa Welch Email

Courtney Rogers is like any 16-year-old. She's learning to drive, looking forward to prom and is proud of her recent yearbook accolade.

"Best hair! I like to do my hair a lot, and I take a lot of time on it."

But a recent health scare made Courtney wonder if she'd be able to enjoy the rest of her teen years. Doctors found a tumor on her spine. It wasn't cancerous -- but still posed dangers.

"Potentially, if I didn't have surgery, I would be paralyzed," said Courtney.

"There were very sleepless nights," said Courtney's mom.

The tumor sat on the surface of Courtney's spine -- a tricky area to reach. The standard way to remove it?

"Through a very large incision in the chest cavity. One that's about 18 inches long, a rib is removed, and the chest cavity is spread widely apart," said Curtis Dickman, M.D., Neurosurgeon at Barrow Neurologic Institute/St. Joseph's Hospital and Medical Center
Phoenix, AZ.

Instead -- neurosurgeon Curtis Dickman used a breakthrough endoscopic technique on Courtney that only a few doctors in the world perform. He made three small incisions in the spaces between her ribs. Special tools were placed through the holes. He clipped the vessels that supplied blood to the tumor and removed the tumor through the chest cavity. Here it is -- about the size of a golf ball.

"It's really a remarkable difference. The pain is much, much less. They get out of the hospital much faster."

In fact-- with standard surgery, it's one to two weeks in the hospital. With the new technique? One to two days. Recovery was two to three months with the old. Now -- it's one to two weeks!

Courtney's tumor is completely gone -- allowing this teen to enjoy all the sweet things in life.

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500,


BACKGROUND: According to the Mayo Clinic, a spinal tumor is a cancerous or noncancerous growth that develops within or near the spinal cord or within the bones of the spine. Back pain is the most common symptom of a spinal tumor. A spinal tumor or a growth can impinge on nerves, leading to pain, neurological problems and sometimes paralysis. A spinal tumor, whether it is cancerous or noncancerous, can be life-threatening and can cause permanent disability.

TREATMENT: Doctors ideally have a goal of completely eliminating the spinal tumor, but this is often complicated by the risk of permanent damage to surrounding nerves. Treatment options may include:
• Monitoring: When spinal tumors are noncancerous and are not growing or pressing on surrounding tissues, doctors may be able to watch them carefully without any other treatment.
• Surgery: This is often the first step for treating tumors that can be removed without risking too much nerve damage. Newer techniques and instruments are allowing neurosurgeons to reach tumors that were once inaccessible. However, not all tumors can be completely removed with surgery.
• Radiation: When a tumor is inoperable or cannot be completely removed, radiation is typically a treatment of choice. It's also a first line treatment for tumors that have spread from other parts of the body.
• Stereotactic radiosurgery: This is a new method that is capable of delivering a high dose of precisely targeted radiation. It is now being studied for the treatment of spinal tumors.

AN EASIER SURGERY: 16-year-old Courtney Rogers had a ganglioblastoma paraspinal tumor. Although this type of tumor is benign, if it's not treated, it could grow and eventually impair movement and the lungs. The tumor was sitting on the surface of Courtney's thoracic spine, within the chest cavity. To remove tumors like this, doctors typically use an open surgery that requires making a 12-18 inch incision into the chest wall, removing a rib, and spreading/fracturing the ribs in order to reach the tumor. This surgery can be disfiguring and painful. It also requires a long recovery. Now, a few doctors around the world, including one at Barrow Neurologic Institute, are using an endoscopic type of neurosurgery where three or four incisions are made in the chest wall to remove the tumor. The hospital stay is usually one to two days, and the recovery is about two weeks. This is a vast improvement over the more traditional surgery.

Carmelle Malkovich
Public Relations
St. Joseph's Hospital and Medical Center
Phoenix, AZ
(602) 406-3319


Curtis Dickman, MD, a neurosurgeon at Barrow Neurologic Institute/St. Joseph's Hospital and Medical Center in Phoenix, AZ, talks about a new, minimally-invasive surgery for patients with spinal tumors.

How rare is it for children like Courtney to get a tumor on their spine?
Curtis Dickman: It’s very rare that she had a very unusual tumor called a ganglioblastoma paraspinal tumor on the surface of the spine.

And that’s not cancer?
Curtis Dickman: It’s noncancerous but it grows inside the chest cavity creating mass effect putting pressure on the lungs. It also can grow along the nerves into the spinal cord causing paralysis.

How big was it when you found it in Courtney?
Curtis Dickman: The tumor was about a little bit bigger than a golf ball.

How great a risk was she for becoming paralyzed? How much larger would the tumor have had to become, how long would it have taken? How important was it that it was found when it was?
Curtis Dickman: It was important we found the tumor when we did, it could have grown over the next few years to compress the spinal cord or to create a large mass inside the chest cavity compressing the lungs.

In the past you would have had a different type of surgery that you would have used.
Curtis Dickman: In the past the way of approaching this type of tumor would be through a very large incision in the chest cavity. One that’s about eighteen inches long in which a rib is removed and then the chest cavity is spread widely apart so that we can fit our hands inside the chest to remove the tumor. The technique that I used was an endoscopic technique and that endoscopic technique inside the chest cavity is called thoracoscopy and we make small incisions in the spaces between the ribs. The way we get access is we put in a special breathing tube and it allows us to block the airflow to one of the lungs and we breath with the other lung. The lung on the side that we’re working deflates when we block the airflow. It’s like a balloon essentially. It creates an empty space inside the chest cavity which allows us to work. So through these small incisions in the chest wall in the spaces between the ribs through one small incision we put the endoscope, which is about the diameter of my finger, through two other openings we put tools to work inside the chest cavity to remove the tumor. And we can do very extensive surgery inside the chest cavity using this technique, this endoscopic technique called thoracoscopy.

Is there a bag that takes the tumor out of the body or how does that work?
Curtis Dickman: No. We actually identify the tumor and its relationship to all the important surrounding structures, the blood vessels, the nerves, the bone structures, the spine as well as the lungs and the heart and the esophagus all the other important structures inside the chest cavity. And then we actually take the blood vessels that are going to the tumor and put clips on those and cut those blood vessels so it essentially amputates the blood supply to the tumor.

So you never take it out you just kill it?
Curtis Dickman: No, no we actually do take out the entire tumor but first we have to defuse the blood supply to the tumor so that it doesn’t bleed as we manipulate the tumor. So it essentially takes the blood supply away from the tumor as the first step. And then we define where the tumor and the normal tissue interface and we circumscribe the tumor. Meaning we go around the edges of the tumor and gently move the tumor away from the normal tissue. And then we were able to identify with Courtney where the tumor was actually infiltrating in to the nerve and you have to sacrifice one of the nerves. But there was no significant loss of function by removing the one nerve that it was attached to. And then I was able to remove the tumor completely from the surface of the spine and I had to cut it in a couple of pieces to remove it through the portal outside the chest wall.
What were the risks doing this endoscopically?
Curtis Dickman: Well there are risks to any of the structures, of injuring the lungs, the blood vessels, the heart. But it’s not high risk because we can see all of those structures and as long as the surgeon is experienced in the technique of thoracoscopy that it’s easy to work in the chest cavity and do this type of technique. There are only a few surgeons in the world that are using this type of technique for spinal application because it’s rare for surgeons to see problems affecting the thoracic spine that could be treated with this technique. What is unique though is that I was one of the first people in the world to develop this technique for spinal applications. I’ve written the only textbook on this topic and so I get referred people from all over the world to be treated with thoracoscopy for spinal problems. That includes tumors that affect the spine, herniated discs that are compressing the spinal cord in the thoracic spine. Excess hand sweating and armpit sweating can be treated with that technique. Fractures and infection, we can actually put screws and rods and spinal instrumentation into the spine using this endoscopic technique. It’s really a remarkable difference because instead of patients having an incision that extends from their back to the front of their chest which is very painful, cosmetically disfiguring and causes problems with lung function after surgery. Higher rate of pneumonia and fluid collecting inside the chest cavity the patients ends up with three or four small incisions in the spaces between the ribs, the pain is much, much less, they get out of the hospital faster. And we’re able to achieve everything that we can achieve with open surgery just as safely if not more safely because a lot of the risks that are present with the open surgery are minimized using this minimally incisional technique or minimally invasive technique.

How many hospital days for traditional surgery? Compare the days to the endoscopic technique.
Curtis Dickman: Compared to one or two days in the hospital it’s one or two weeks in the hospital for the open surgery.

What about the recovery time for open surgery and the new technique?
Curtis Dickman: The recovery time is more than cut in half.

Like how many weeks?
Curtis Dickman: It depends on the particular problem. For a tumor like Courtney has instead of a one to two week recovery with the endoscopic approach it would be a two to three month recovery with an open thoracotomy.

For Courtney, a sixteen year old girl, she’s back to being sixteen where before it would have taken months.
Curtis Dickman: It’s a wonderful benefit for Courtney it’s also a wonderful option for anyone that has a problem affecting the thoracic spine that requires surgery through the chest cavity. To use this technique has vast advantages compared to open surgery. But the caveat is that they have to have a surgeon that has tremendous a tremendous amount of experience using this technique. A surgeon can’t use this technique once or twice a year and be good at it and keep the skills up. The surgeon has to be able to use this technique on a regular basis. And because this is a rare kind of problem most spinal surgeons, neurosurgeons and chest surgeons don’t get to keep their skills up using this technique on a regular basis. So I think that’s why I have such a high volume of referrals of people needing surgery with this technique.

With this specific thing for Courtney was she your first?
Curtis Dickman: She was my first patient with this type of tumor but we just published the results of my first twenty-seven patients treated with spinal tumors with the thoracoscopic approach. And I have performed over seven hundred surgeries using thoracoscopy for a variety of spinal problems.

What were the results of your study?
Curtis Dickman: The results of the study were very good. In every single patient we cured the tumor, none of the patients required a blood transfusion. They averaged only a few days in the hospital, very quick recovery so it was a very good study.

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

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