Paediatric and Adult Scoliosis
Cervical and lower back disc herniations, fractures and dislocations, infections, tumours, spondylolisthesis and degenerative spine problems are treated using the latest scientific developments at our Scoliosis and Spine Surgery Centre. Our Clinic was the first in Turkey to start "endoscopic treatment of herniated discs" in 2002 and "total disc arthroplasty" in 2003 and since then, they have been successfully performed.
Our Clinic is considered as a world example for the treatment of spinal diseases. It is among the centres with the greatest experience in vertebral resection and scoliosis surgery performed posteriorly. It can be used especially for various diseases from fractures to spinal tumours. All patient examinations are evaluated by specialists, pain and physiotherapists and radiologists. The appropriate treatment methods for each patient are scientifically determined, such as conservative treatment (administration of drugs and physiotherapy), nerve root and facet joint block, endoscopic or open surgery.
Through the EOS method for patients with spinal disorders, it is possible to use up to 10 times lower radiation doses than traditional radiography.
Our centre hosts a large number of regional and international meetings each year. A large number of local and foreign scientists and collaborators visit our department and participate in research.
Scoliosis
Scoliosis is a significant sideways and/or rotational curvature of the spine in all three dimensions that can occur in the upper and/or lower back. The vertebrae are positioned in a vertically straight line in the normal and healthy person. In scoliosis, the spine is curved to the left or right and is also curved on its own axis. Such curvatures may be in only one part of the spine or in more than one and in a different direction.
Scoliosis is more common in adolescence. It can cause cosmetic and irreversible damage to the heart and respiratory system. If not intervened at an early stage. To identify the disease, it is important for patients to self-monitor and observe their body shape to spot the signs.
These signs include:
- Difference in shoulder level
- Asymmetry in waist dimples
- Anterior protrusion of one part of the spine
- Convex bones on one side of the back (convex scapula appearance)
- Right and left deviation in body balance
The method of treatment is determined based on the size of the curvature and the stage of development of the bone. The earlier treatment is started, the higher the success rate.
Surgical treatment: surgical treatment is the only option when the curvature is greater than 40 degrees and in patients who are still in the developmental stage. Surgical treatment is successfully performed with the use of implants (screws) that are placed in the back and lower back.
Monitoring (neuromonitoring) of spinal cord function during surgery is a method that increases the reliability of surgery for both the patient and the physician and is routinely used at our centre. Our clinic is one of the reference centres worldwide for scoliosis surgery.
The surgical process is organized in a highly professional manner for the greater comfort of the patients. Your doctor determines which chiropractic method to apply depending on the type of scoliosis and the surgery is explained to the patient in detail. Only a single operation is sufficient in 90% of patients to achieve a favourable result. Patients are up and walking one day after surgery. The length of hospital stay is about 5 days. Patients can usually return to their daily activities within 3 weeks after surgery.
Kyphosis
In a normal spine, the upper back has a curve called kyphosis and the opposite of it, the lumbar region has a curve called lumbar lordosis.
The normal spine in its thoracic region has a slight kyphosis between the 1st and 12th vertebrae, with an angle of 20 to 45 degrees. It is called hyper-kyphosis when the curve at the top of the spine is greater than 45 degrees.
Congenital kyphosis: treatment depends on the type and severity of the condition. Surveillance is the first line of treatment for children with spinal deformities. Serious and progressive congenital kyphosis deformities that are greater than 45 degrees or cases of kyphosis accompanied by neurological weakness often require surgical treatment.
An early surgical approach usually provides the best outcome and prevents progression of the deformity. The type of surgical intervention to be performed may change based on the nature of the deformity, such as in-situ fusion, instrumented fusion and osteotomy (rods, hooks and screws). Your surgeon may recommend an osteotomy to realign your spine. A pedicle subtraction osteotomy ossifies the correction by removing the bone at the back of the vertebra. A vertebral resection osteotomy can also be applied. Our Centre has world-renowned experience in vertebral removal interventions from the back.
Growth Kyphosis:
Also known as Scheuermann kyphosis, it is defined as a stiff (structural) kyphosis. It is most common between the ages of 12 and 15. Unnatural kyphosis is best seen by looking at the side in a forward-curved posture. Patients with Scheuermann kyphosis often have poor posture and complain of back pain.
In the following cases, observation is often recommended:
- Hyper kyphosis in body posture
- Curvature less than 60 degrees during adolescence
- Curvature of 60-80 degrees in incomplete adolescence
- Corset treatment and an exercise program may be recommended if the deformity is moderately severe (60-80) and if the patient has not completed skeletal development.
Surgical Treatment:
Spinal fusion may be recommended if the kyphotic deformity is severe (greater than 80 degrees) and if the patient's pain is increasing. The spine is corrected and lengthened by fixing the screws placed in the vertebrae with rods. Patients can return to their daily activities within 4-6 months. The change made by surgical correction is visible.
Traumatic kyphosis: kyphosis treatment is designed to correct and stabilize the deformity, reduce pain and improve neurological function. Movable deformities can be treated with posterior fusion and instrumentation (connecting the vertebrae with screws and rods). Immobile deformities often require more serious surgery, such as removal or resection of vertebrae. All these interventions are performed by the experienced surgeons in our Clinic.
Cervical Disc Herniation
Discs consist of tough connective tissue and work as a pad or shock absorber between the vertebrae. A herniated disc in the neck called cervical disc herniation occurs when the disc body between the vertebrae is displaced toward the spinal cord or nerve roots. A cervical disc herniation often results in neck pain, pain that spreads down the arm and numbness of the arm accompanied by changes in sensation.
Treatment:
A cervical disc herniation usually proceeds favourably. Initially, patients should receive conservative treatment. It includes examinations, placement of a rigid cervical collar, use of analgesics and muscle relaxants, and physiotherapy exercises. Steroid injection through the foramen may be beneficial in some patients to calm the nerve roots. Surgical treatment should be considered for patients with severe neurologic symptoms, such as loss of sensation and mobility, and especially for patients with myelopathic symptoms and those who have not responded favourably to conservative therapy.
The goal of the surgery is to remove the part of the disc that is compressing the nerve. Once the disc that is causing the pinching is removed, a vertebral fusion (fusion) is often performed. Another treatment option offered by our Centre is disc replacement, which is preferred to preserve mobility, especially in young patients.
Cervical Degenerative Disease
Degeneration of the cervical spine begins in the intervertebral discs, leading to secondary changes in other adjacent joints. This process in the spine is defined as 'spondylosis'. In spondylosis, small bony growths called osteophytes appear around the spinal canal and nerve roots. Factors that cause disc disease in the cervical spine include aging, overuse and trauma, prolonged work in an awkward posture, genetic causes, smoking, vascular disease and diabetes or chronic rheumatic diseases. Cervical spondylosis leads to pain in the neck, shoulders and arms as it pinches nerve roots. The pain can extend to the arm or hand through specific spreading of the nerve root under pressure. If a cervical disc herniation compresses the spinal cord, problems with walking, spasticity (increased muscle tone) and urinary incontinence may occur.
Treatment:
Usually, the initial treatment is conservative; instruction, rigid cervical collar placement, physiotherapy exercises and painkillers are the most common treatment methods for patients. If the complaints persist, or neurologic findings are found, or deterioration occurs despite conservative treatment, surgical treatment should be considered. The surgical intervention depends on the pathology causing the patient's condition. The most commonly used surgical approaches are frontal and posterior. Frontal approach: the cervical spine is accessed by entering from the front of the neck.
The herniated disc between the vertebrae and the bony prominences that cause compression of the bone marrow are removed. This is called a corpectomy. In the space left by these, a support of implant or bone from the patient, or an artificial bone graft can be placed.
Posterior approach: this is based on removing the posterior membranes of the vertebrae (laminectomy) and easing the spinal cord canal. It is performed in spinal stenosis at one or more levels. If necessary, posterior fixation using titanium screws can also be performed to maintain stability after removal of the posterior membranes.
Thoracic /Thoracic/ Disc Herniation
Approximately 0.25 - 0.75% of all disc herniations of the spine occur in this area. The nerve roots between the vertebrae stretch to the thoracic region and cause pain and a burning sensation on the ribs because of the pinching of the nerve roots caused by the disc herniation. The most common symptoms in patients include pain and changes in sensation accompanied by loss of mobility and sensation in the lower extremities.
Treatment:
Physical therapy exercises may be helpful. If complaints persist and become progressive, then it is necessary to remove the disc with a surgical procedure. It is possible to remove the part that is causing the pinching using microscopic or endoscopic methods.
Lumbar Herniated Disc
Lumbar spine is made up of five vertebrae. There is a special disc-shaped connective tissue that facilitates movement between the vertebrae and allows the spine to be strong, and also functions as a shock absorber. The disc consists of two parts, an outer layer and an inner layer. The soft layer inside is pushed outwards as the outer layer deforms. The herniated part compresses the nerves of the spinal canal and keeps them that way.
Sometimes the herniated part releases chemicals that cause pain. All of this is called lumbar herniated disc. Lumbar herniated discs in young people is most often associated with lifting heavy objects or forced movements in the lumbar region. In the elderly, smaller but repetitive forced movements in the lumbar region over the years can lead to a herniated disc over time.
The most common complaint of patients with herniated disc is lower back pain that radiates down into the legs and feet. In more advanced cases, in addition to pain in the lower back and legs, problems such as numbness and weakness may occur. In untreated cases, problems such as loss of movement up the ankle, which we call drop foot, and urinary incontinence may occur.
Treatment:
The primary goal of herniated disc treatment is to relieve pain to allow patients to return to their normal daily activities. The first thing to do is bed rest and medication, and then patients should be educated.
The structures around the spine are strengthened and the body mass is distributed more evenly through physical therapy exercises so that the load on the disc can be partially reduced, complaints minimal. Epidural injections and blocks are other methods that are used to eliminate patients' pain.
In case of loss of strength and sensitivity in the legs and feet or conservative methods fail to cope with the patient's complaints, part of the herniated disc is surgically removed to free the nerves.
In addition to open surgery, microscopic and endoscopic methods can be used in lumbar disc surgery, depending on clinical and radiological findings. Another method that is used in our clinic is the disk prosthesis. The use of a disc prosthesis in appropriate patients will preserve spinal mobility and allow pain relief. Maintaining mobility helps avoid degenerative problems that may occur in the future.
Lumbar Degenerative Disc Diseases and Spinal Stenosis
The discs between the vertebrae lose their spongiform nature and begin to contain less water with age. This leads to a reduction in height and calcification of the disc that protrudes into the spinal canal. Any bony growths, called osteophytes, that form in the body limit spinal mobility and compress nerves. All these changes lead to a narrowing of the spinal cord, which is called either spinal stenosis or narrow canal.
The most common complaint in patients with spinal stenosis is back pain. Characteristic of the pain is an increase in sitting position, walking, coughing and straining, and decreased in a state of rest. Neurogenic lameness, which is a typical sign of spinal stenosis, is characterized by sensations of pain, numbness, a sensation of spines in the legs, especially in the calves when walking, which are dulled at rest.
To aid the diagnosis, it is possible to examine all the vertebrae and the legs from the skull to the feet in the same image and thus look at balance disorders in the body, by means of an EOS-graph technique that we have at our hospital.
Treatment:
Treatment begins with bed rest accompanied by analgesics and relaxants, then physical therapy is approached. An epidural steroid injection may also be considered. In the event that the pain is very strong, does not respond to conservative methods and significantly limits the patient's daily activities, then surgical treatment may be necessary. The main goal of surgical treatment is to remove pressure on the spinal cord.
This is called decompression and is done by removing the bony structures (laminectomy) that form the back wall of the spinal canal through an intervention from the lower back. Another method of decompression is to remove the discs that are causing the compression. The space that remains between the vertebrae after the discs are removed is supported by placing titanium cages that are filled with bone graft. This intervention can be performed with Anterior Lumbar Interbody Fusion (ALIF), Extreme Lateral Interbody Fusion (XLIF) or through Transforaminal Lumbar Interbody Fusion (TLIF).
The possibility of balance and stability of the spine, through screw fixation, also with posterior access (posterior implantation of instruments) is vital to ensure postoperative patient comfort and to avoid disease recurrence. The return of the normal physiological curvature of the spine (spinal balance) should be achieved after surgical treatment.
Spondylosis and Spondylolisthesis
Spondylolisthesis is when one vertebra slips forward over the one below it. With a slip, the spinal cord is pressed into the spine, resulting in pain, numbness, and a burning sensation in the legs. It is categorized into five different types. The most common include slippage related to aging, slippage that developed postoperatively, and slippage related to congenital spinal problems in childhood.
5% of people have a growth fracture of the bone that connects the upper and lower joints (facet joints) of the vertebrae in the lower back. This fracture is called spondylolysis. Fractures often fail to connect because the site is very mobile. In some patients, the upper vertebra is displaced forward over the lower vertebra because of the fracture. This is called lumbar slippage or spondylolisthesis. Spondylolisthesis may lead to more serious problems, depending on the extent of the slippage.
Another type of lumbar slippage is caused by the wear and tear of the tendons in and around the spine due to aging. This problem, which often occurs after the age of 40, is called degenerative spondylolisthesis. Degenerative lumbar slips are often accompanied by a narrowed canal. Symptoms include back and hip pain; numbness, pain, muscle tension, weakness in the legs; increased lumbar curve or difficulty walking. While rest may bring temporary relief to these symptoms, the pain usually worsens with standing, walking, and other activities.
Treatment:
In mild cases of slippage, complaints will resolve with rest, analgesics, temporary use of a brace, and physical therapy. An epidural or foraminal injection may be considered. If adolescent stress fractures cause pain and limit the adolescent's mobility, then operative treatment should be undertaken.
The preferred method is usually to reinforce with fresh bone graft for fusion of the fractured part and fix it with screws and hooks. The experienced doctors at our clinic will perform this operation, even for just one vertebra. In this way, a quick recovery is achieved and our patients return to their usual activities without restrictions in lumbar movements.
In the case of slippage in old age, if the disease causes complaints that cannot be reduced by drugs, gives signs of nerve compression (dropped foot, urinary incontinence) and progresses, then surgical treatment is necessary. The nerves in the area of the slip are released by surgical treatment and the vertebrae are fixed to each other to avoid progression of the slip. The operation can be performed with an anterior or posterior approach or with an approach from either side. The recovery process is supported by post-operative rehabilitation programs. The team of physiotherapists of our hospital starts rehabilitation of patients from the first day after the operation. Before being discharged from the hospital, patients are thoroughly trained in daily activities. For example, how to get out of bed, how to walk and climb stairs.
Sudden (Sharp) Pain in the Lower Back
Lower back pain may occur after activity or trauma, or it can occur for no specific reason. Studies conducted worldwide show that 80% of people suffer from lower back pain at least once in their lives. It is often difficult to determine the exact source of acute lower back pain. The first thing that comes to the mind of people who suffer from such pain is the possibility of a herniated disc. In fact, many causes can lead to pain in this area and the most common type is mechanical pain in the lower back, which is often the result of overloading the lumbar muscles, muscle fibres and tendons or from pressure.
The good news is that despite the fact that the exact source of the pain cannot be identified, the acute pain spontaneously reduces over time. The pain completely resolves within approximately 2 weeks in 50% of cases. Unfortunately, it is impossible to determine how long the pain will last, depending on its location and initial intensity. One should know that 30% of people have recurrent pain.
Pain that is caused by a more serious illness is most common in people over the age of 50, those with past cancer and excessive alcohol or drug use or in cases of long-term corticosteroid use, as well as in patients who have another underlying problem such as diabetes or osteoporosis and in patients who experience severe pain even when resting.
The best recommendation for acute lower back pain is to endure the pain and continue with daily activities. The general tendency of patients is to rest in bed and wait for the pain to go away. In fact, muscle movements increase blood flow and thus reduce inflammation and muscle tension.
Paracetamol and other analgesics are often used to reduce the intensity of lower back pain. Various physical therapy exercises (deep or superficial heating, transcutaneous electrical nerve stimulation, electrical stimulation, etc.) as well as massage therapy may temporarily relieve pain.
Traditionally, acute low back pain does not require radiological diagnostic studies in most patients. Radiological diagnostic studies (x-ray, computed tomography, magnetic resonance imaging) may be recommended in cases of health problems, such as serious injury, past cancer, presence of fever, diabetes and addiction and for patients over 50 years of age and with diagnosed osteoporosis.
Although acute lower back pain can be a painful experience for patients, in most cases it is possible to quickly eliminate the pain. A detailed medical examination is mandatory, especially in cases where the pain lasts longer than six weeks. The goal of treatment should be to eliminate the acute pain and prevent its recurrence. This is why it is so important to instruct the patient and start and maintain an exercise program at an earlier stage.
Vertebral Fracture
Vertebral fractures have a different significance than other bone fractures due to risk of affecting the nerve structures in them. This may lead to damage of the vital vessels and organs that surround them.
Vertebral fractures in adolescents are often caused by high-force trauma, such as a fall from a height or a car accident.
In adults, such a fracture may occur from simple trauma associated with osteoporosis and even without trauma. Fractures and dislocations of the cervical (neck) vertebra may lead to respiratory distress, which may lead to death or complete paralysis of the hands and feet. Lumbar injuries may lead to paralysis of the legs and complaints of urinary or faecal incontinence. Basically, the first complaint of patients with a vertebral fracture is pain accompanied by muscle spasms.
If the fracture is accompanied by a vertebral injury, complaints may include numbness, loss of sensation in the hands and/or feet, loss of strength, urinary and faecal incontinence, and difficulty urinating or defecating. Failure to transfer patients to an appropriate position is one of the most important factors affecting injury fatality.
Treatment:
Treatment for spinal injuries varies depending on the type of injury and whether a spinal cord injury is present. The goal of treatment is to achieve a spine that cannot be damaged by normal physiological forces and patients may return painlessly to their daily activities as soon as possible.
If the injury has caused an unstable fracture or dislocation with a fracture, has resulted in or is at risk of causing damage to the spinal cord, then surgical methods of treatment will be used. Surgical treatment often uses screws and rods applied posteriorly to restore vertebral stability.
Insertion of rods may also be performed by closed methods when possible, thus reducing postoperative hospital stay and pain.
Vertebroplasty or kyphoplasty methods are used for fractures associated with osteoporosis. In vertebroplasty, the vertebrae are injected with bone cement to eliminate pain and prevent progression of the distortion. In kyphoplasty, the misalignment is corrected by inflating a balloon inside the vertebra before cement is injected.
Both methods involve radiological imaging called fluoroscopy and are performed with closed access (no incisions) at our Centre.
Another method of treatment is a stent. Our Clinic began using it for the treatment of vertebral fractures at the same time it began to be used around the world. In this method, the distortion is corrected by placing cells inside the vertebra without incisions. Patients treated with this method may return to their daily activities and activities quickly and painlessly.
Spinal Infections
Spinal infections include spondylitis, discitis, spondylodiscitis, and epidural abscess and are caused by a variety of microorganisms. Bacterial infections of the spine are the most common type of infection in this group. Infections are often carried through the bloodstream to the vertebrae. Certain groups of patients are at greater risk of infection, for example, those who smoke cigarettes, who are malnourished, or who suffer from AIDS or another disease.
Infections cause violation of the immune system. For patients receiving chemotherapy, transplant patients, diabetics, drug abusers, and those who have had surgery on the urinary system, infection may occur after surgery.
Treatment:
Active microorganisms should be determined by biopsy of the infected area. As soon as they are identified, appropriate antibiotic treatment is started immediately. Treatment often includes rest and the use of a corset.
The infected area may require surgical drainage, depending on the type and stage of the disease. Early surgical intervention may be necessary to avoid progressive paralysis in some cases, especially in patients with vertebral osteomyelitis and infections that cause neurological damage.
Spinal Tumours
Spinal tumours form in the bones that form the spinal canal or in the nerves or other soft tissues. The origin of the tumour mainly includes two types: Primary tumours – they are formed from the cells that are contained in the spine and in the spinal cord. Metastatic tumours, which develop in other parts of the body (breast, prostate, lungs, etc.). Then they spread and reach the spine. The most common complaint is back pain. The pain is worse at night and usually does not subside with rest.
Chronic symptoms of the disease may occur, such as fever, weight loss, exhaustion. Depending on the localization of the tumour and whether it causes compressive weakness, numbness and tingling in the hands and feet, inability to walk, urinary incontinence, uncontrollable defecation, loss of sexual functions, deterioration of reflexes, bed rest may be required. Loss of strength, seizures and scoliosis can occur in children.
Treatment:
Depending on the type and location of the tumour, treatment methods such as surgical intervention. Radiation therapy and immunotherapy can be used in combination or separately. For some patients, monitoring alone may be an appropriate choice. Making such a decision usually requires a spine surgeon, radiologist, and oncologist to work together.
Benign tumours that do not cause compression can be monitored periodically. Tumours that need to be removed with a surgical procedure are tumours that cause neurological symptoms or a fracture. There is a risk of causing a fracture.